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Article

Burnout and Contributing Factors to Burnout Among Indonesian Healthcare

Workers Before and During COVID-19 Pandemic
Monalisa Simbolon1, Masyitoh Bashabih1
1
Faculty of Public Health, Universitas Indonesia, Depok, Indonesia

Abstracts
Introductions: The prevalence of burnout among health work-
Submitted : August 8, 2023
ers in Indonesia varies. During the Coronavirus Disease 2019
Revised : September 19, 2023
Accepted : October 10, 2023 (COVID-19) pandemic, there was an increase in burnout among
Published : November 10, 2023 health workers. Many factors can affect the prevalence of burn-
out in health workers. Objectives: to provide an overview of the
prevalence and factors that influence burnout among healthcare
You are free to:
workers in Indonesia Methods: The writing of this article uses
Share — copy and redistribute the the literature search method. Literature searches used the Pubmed
material in any medium or format and Google Scholar search engines, using literature within a time
limit of 3 years before and three years during the COVID-19 pan-
Adapt — remix, transform, and build demic. Results: It is known that the prevalence of burnout before
upon the material for any purpose, the COVID-19 pandemic reached 19.8%–62.85%, and during the
even commercially.
COVID-19 pandemic reached 5.2%–82%. For factors that affect
The licensor cannot revoke these burnout before and during the COVID-19 pandemic, there is not
freedoms as long as you follow the much difference between factors such as age, gender, marital status,
license terms. type of work, workload, stress level, length of service, number of
hours worked per week, and level of education. In several studies
before the COVID-19 pandemic, additional factors such as religios-
ity, work environment, and organizational structure leadership were
found. In contrast, during the COVID-19 pandemic, there were oth-
er risk factors, namely the risk of transmission of COVID-19, edu-
cational background, and access to psychological services. Conclu-
sions: By knowing the factors related to burnout, it is hoped that it
can be used as a step to form an effective and efficient management
system to overcome burnout
Correspondence Author:
Keywords: Burnout, COVID-19, epidemiology, healthcare workers,
Email: [email protected]
mental health

Cite this as: Simbolon. M., Basabih. M. “Burnout and Contributing Factors to Burnout Among Indonesian Healthcare Work-
ers Before and During COVID-19 Pandemic”. Jurnal Psikiatri Surabaya, vol. 12, no. 2, pp.114-125, 2023. doi: 10.20473/jps.
v12i2.48468

114
 Simbolon - Burnout and Contributing Factors

Introductions gle Scholar are used to conduct a literature

search. Indonesian and English literature
When a job is not carried out or adequately courses are offered. Three years (2017–
organized, this will have an impact on the 2019) are utilized as the pre-pandemic peri-
worker, namely burnout. Burnout is a stress od, and three years (2020–2022) are regard-
or psychological syndrome when a person ed as the pandemic period in the literature. A
experiences chronic job stress [1,2]. The study that discusses the incidence of burnout
term burnout was introduced by Freuden- and its causes must be considered literature;
berger (1974) when he observed several the studies must be fully accessible. In this
workers in mental healthcare clinics who ex- article, the term “healthcare workers” refers
perienced a loss of motivation and decreased to those working in the medical field, includ-
commitment. Then, Maslach et al. developed ing nurses, general practitioners, and spe-
a measuring tool called the Maslach Burnout cialists. The words “burnout,” “prevalence,”
Inventory (MBI), which is most often used “physician,” “nurse,” “healthcare workers,”
to measure burnout [2,3]. and “Indonesia” are used in English, where-
The prevalence of burnout in various popu- as “burnout,” “prevalence,” “dokter,” “per-
lations of healthcare workers has varied be- awat,” and “tenaga kesehatan,” in Indone-
tween studies. For example, it is estimated sian, are employed.
that 76.9% of surgeons experience burnout According to Pubmed search results, there
[4], 11.23% of nurses [5], and 2.46-70.25% were 64 burnout articles in Indonesia (be-
of general practitioners [6]. During the Coro- fore the COVID-19 pandemic) and 135
navirus Disease (COVID-19) pandemic of articles (during the COVID-19 pandem-
2019, there was an increase in the incidence ic). According to a Google Scholar search,
and severity of burnout among medical per- there were 584 publications (published be-
sonnel [7,8]. Burnout can have a significant fore the COVID-19 pandemic) and 2057
negative impact on sufferers. Someone with articles (published during the COVID-19
burnout can experience abuse, damage to pandemic). There were nine articles (before
relationships with other people, and even the COVID-19 pandemic) and ten articles
suicidal thoughts. Regarding work perfor- (during the COVID-19 pandemic) that were
mance, burnout in healthcare workers can accessible after being chosen from a pool of
cause therapeutic errors in patients, report- research articles with a sample of healthcare
ing errors, and malpractice . workers, figure 1.
Various factors are known to influence the
occurrence of burnout in healthcare work- Identification of studies via databaseand registers

ers. These factors include young age, low

income, piling up of cases, lack of time with Records identified from:
Pubmed
Identification

family, complicated issues, excessive work-

- Before the COVID-19 pandemic (n= 64)
- During the COVID-19 pandemic (n= 135)
Google Scholar
ing time, type of specialization, and so on - Before the COVID-19 pandemic (n= 584)
- During the COVID-19 pandemic (n=2057) Criteria included:
[9–11]. Studies on burnout have been carried - Research article
- Study location in Indonesia

out in many countries, including Indonesia.

- Indonesia and English
- Pre pandemic periode (2017-2019)
- Pandemic period (2020-2022)
This article aims to describe the prevalence Records included:
- Before the COVID-19 pandemic (n = 9)
- Open access

of burnout and the factors that influence it in - During the COVID-19 pandemic (n = 10)
Screemimg

healthcare workers in Indonesia before and

during the COVID-19 pandemic. Reports assessed for eligibility (n = 19)

Method
Using information from a literature search,
Included

Studies included in review (n = 19)

this article was created. Pubmed and Goo-
Jurnal Psikiatri Surabaya | Vol. 12 No. 2 November 2023 115
 Simbolon - Burnout and Contributing Factors

Reviews work environment, stress level, spirituality/

The prevalence of burnout in Indone- beliefs, limited access to psychological ser-
sia before and during the pandemic is about vices, level of education, marital status, lead-
19.8%-62.85% and 5.2%-82% (table 1 and ership management, contact with COVID-19
table 2). Factors that influence healthcare patients, seniority and type of job (table 3).
workers in Indonesia before and during the Table 1. Prevalence and factors related to
COVID-19 pandemic are age, gender, work burnout in healthcare workers (before the
experience history, workload, working time, COVID-19 pandemic)

Table 1. Prevalence and factors related to burnout in healthcare workers (before the
COVID-19 pandemic)
Years Sample Locus study Prevalence Factor associated Ref
burnout
2017 138 nurses Cilandak Marine The prevalence of Related factors: [12]
Hospital, South severe burnout is heavy workload and
Jakarta 59.4%. poor work
environment.
2017 86 nurses Sanglah General The prevalence of Related factor: work [13]
Hospital, severe burnout experience history
Denpasar reached 19.8%, and
moderate burnout
reached 22.1%.
2017 31 nurses General hospital The prevalence of A related factor is [14]
Prof. Dr. Margono severe burnout stress level.
Soekarjo, reached 22.6%, and
Purwokerto moderate burnout
reached 48.4%.
2018 4092 Army Central The prevalence of Physician [15]
healthcare Hospital Gatot burnout reaches Protective factors:
workers in Soebroto, Budhi 49.2%. having a religion,
ICU, Asih General number of years
multinational District Hospital, working in the
study Dr. Soetomo current department,
(Indonesia: 61 Hospital, having work shifts,
participants) Grestelina General stay-home night calls
Hospital, per month.
Soetomo Hospital Related factors:
Surabaya, Mitra number of working
Satelit Surabaya, days/month
National Hospital, Nurse
Prima Satya Protective factors:
Husada Citra have a religion, can
Hospital, Royal balance personal-
Taruma Hospital, work life.
RS Panti Wilasa, Related factor: high
RSUD Raden level of education

2018 197 nurses Raden Mattaher The prevalence of A related factor: [16]
Hospital and Abdul moderate burnout high workload
Manap Hospital, is 50.8% and
Jambi severe burnout
(28.4%)
2019 70 midwives Health Center in The prevalence of Related factors: [17]
Bengkulu City severe burnout is young age and low
60% work motivation.
2019 485 nurses Dr Saiful Anwar The prevalence of Gender and work [18]
Hospital, Dr nurses with experience related to
116 Jurnal PsikiatriSoetomo
Surabaya
Hospital,
| Vol. 12 No. 2signs
symptoms of
November
of emotional
2023
Ngudi Waluyo emotional exhaustion; marital
Hospital exhaustion is status about
47%, symptoms of
depersonalization decreased self-
 2018 197 nurses Raden Mattaher The prevalence of A related factor: [16]
Hospital and Abdul moderate burnout high workload
Manap Hospital, is 50.8% and
Simbolon - Burnout and Contributing Factors
Jambi severe burnout
(28.4%)
2019 70 midwives Health Center in The prevalence of Related factors: [17]
Bengkulu City severe burnout is young age and low
60% work motivation.
2019 485 nurses Dr Saiful Anwar The prevalence of Gender and work [18]
Hospital, Dr nurses with experience related to
Soetomo Hospital, symptoms of signs of emotional
Ngudi Waluyo emotional exhaustion; marital
Hospital exhaustion is status about
47%, symptoms of
depersonalization decreased self-
(48%), and satisfaction;
dissatisfaction respondent's age and
with self- employment status
achievement related to
(48.8%). depersonalization
symptoms
2019 35 nurses Pekanbaru Medical The prevalence of Related factors: [19]
Center Hospital. burnout reaches heavy workload and
62.85%. authoritarian
organizational
leadership.
2019 58 nurses Inche Abdoel Meois The prevalence of Related factor: head [20]
Hospital, Samarinda severe burnout nurse leadership
reaches 53.9%. style

Table 2. Prevalence and factors related to burnout in healthcare workers (during the
COVID-19 pandemic)

Years Sample Locus study Prevalence Results Ref

2020 34 nurses Bhayangkara The prevalence of Related factors: age, gender, marital [21]
Hospital, Palembang moderate burnout is status, education, work experience
41.2%. history, workload, and stress at
work.

2020 39 nurses Queen Zalecha The prevalence of Related factors: there is no [22]
Martapura Hospital, severe burnout relationship between age, education
Banjar reaches 46.15%. level, work experience history, and
stress at work on the incidence of
burnout.

2021 544 healthcare The specific location The prevalence of Related factors: contact with [23]
workers is not mentioned burnout reaches COVID-19 patients
consisting of 42.4%; in the high-
doctors (144 risk group of
people), nurses healthcare workers
(124 people), (contacts with
others (276 COVID-19 patients),
people) 26.6% experienced
burnout compared to
those who did not
contact patients with
COVID-19 (15.8%).

2021 683 The specific location The prevalence of Associated factors: stress at work, [24]

Jurnal Psikiatri
gastroenterolo Surabayaburnout
is not mentioned | Vol. 12 No.
is 5.2%. 2 November
The depression, 2023
lack of access to 117
gists, prevalence of doctors psychological services.
multinational with symptoms of
research emotional exhaustion
(Indonesia: is 12.3%,
195 depersonalization
 burnout compared to
those who did not
contact patients with
COVID-19 (15.8%).
Simbolon - Burnout and Contributing Factors

2021 683 The specific location The prevalence of Associated factors: stress at work, [24]
gastroenterolo is not mentioned burnout is 5.2%. The depression, lack of access to
gists, prevalence of doctors psychological services.
multinational with symptoms of
research emotional exhaustion
(Indonesia: is 12.3%,
195 depersonalization
respondents) (4.6%), and
dissatisfaction with
self-achievement
(25.1%).

2021 841 pediatric The specific The prevalence of Related factors: [25]
residents location is not fatigue symptoms is
mentioned 52%, and Symptoms of fatigue: class

disengagement is 63%. (junior)

Symptoms of disengagement:
marital status, generation
2022 1077 Saiful Anwar The prevalence of Related factors: male gender, [26]
healthcare Hospital, burnout is 22%, with young age (<40 years), single,
workers Kanjuruhan symptoms of severe doctor, and long working hours
consisting of Hospital, Persada emotional exhaustion at (>70 hours/week)
doctors (427 Hospital, Panti 20.6%, severe
people), nurses Waluya Hospital, depersonalization
(549 people), Wava Husada (9.8%), and severe
others (101 Hospital dissatisfaction with self-
people) achievement (0.9%).
2022 86 residents The specific location The prevalence of Related factors: complicated case [27]
is not mentioned residents with finding (for the depersonalization
symptoms of severe domain), surgical residents (for the
emotional exhaustion emotional exhaustion domain), and
(31.4%), moderate high working hours (for the self-
(29.1%); severe dissatisfaction domain).
depersonalization
(25.6%), medium
(24.4%); and extreme
self-achievement
dissatisfaction (46.5%),
average (20.9%).
2022 120 surgical Tertiary referral The prevalence of Associated factors: high working [11]
residents hospital residents with hours (> 70 hours/week); marital
symptoms of severe status, surgical specialty, years of
emotional exhaustion residency, and working hours
(12.5%), moderate related to emotional exhaustion;
(15.0%); severe surgical specialty related to
depersonalization depersonalization.
(13.33%), medium
(19.17%); and severe
self-achievement
dissatisfaction
(43.33%), average
(25.83%).
2022 1381 The specific location The prevalence of Associated factors: high risk [28]
healthcare is not mentioned burnout reaches 18%. (contact with COVID-19 patients),
workers working hours longer than usual,
(multinational lack of adequate personal protective
118 Jurnal
study, 368Psikiatri Surabaya | Vol. 12 No. 2 November
equipment, 2023
and poor teamwork.
from
Indonesia)
 (13.33%), medium
(19.17%); and severe
self-achievement
dissatisfaction
Simbolon - Burnout andaverage
(43.33%), Contributing Factors
(25.83%).
2022 1381 The specific location The prevalence of Associated factors: high risk [28]
healthcare is not mentioned burnout reaches 18%. (contact with COVID-19 patients),
workers working hours longer than usual,
(multinational lack of adequate personal protective
study, 368 equipment, and poor teamwork.
from
Indonesia)

Table 3. Summary of prevalence and factors influencing burnout before and during the
COVID-19 pandemic

Before COVID-19 pandemic During COVID-19 pandemic

Prevalence 19.8%-62.85% 5.2%-82%
Factors related Age [19], [20] Age [23, 28]
burnout Gender [20] Gender [23, 28]
Marital status [20] Marital status [23,27,28,30,32]
Type of job [20] Type of job [28-30, 32]
Workload [14, 18, 21] Workload [23]
Environment [14] Risk transmission of COVID-19
Stress level [16] [25, 31, 32]
Work experience history [15, Stress level [23, 24, 26]
17] Work experience history [23, 24]
Number of days/hours worked Number of days/hours worked per
per week [17] week [28-31]
Spirituality [17] Education level [23, 24]
Education level [17] Junior education [27, 30]
Leadership organizational Access to psychological services
structure [21, 22] [26]

Discussion Burnout was shown to be extremely com-

Results of various burnout prevalence levels mon (82%), according to a different study by
were found in this literature search. Various Soemarko et al. [29]. This may be because
factors, including diverse burnout measure- there was a greater sample size and a more
ment tools in various studies and variations comprehensive range of healthcare profes-
in working conditions, bring about this vari- sionals (most general practitioners, mid-
ation. For instance, the study by Ong et al. wives, and nurses). Most of the three profes-
[24] discovered that the prevalence of burn- sions work as front-line healthcare providers
out among gastroenterologists (195 respon- who interact with patients for the first time
dents) was 5.2%. Even though Indonesia before referring them to specialists or other
had the fewest cases of burnout among other healthcare professionals who are more qual-
Southeast Asian nations regarding patient ified to handle their care, making it possible
volume, this prevalence was still higher than for this study or other studies to determine
those of several other nations in the region. the prevalence of burnout.
This might occur because gastroenterolo- There is a relatively significant dif-
gists in Indonesia work an average of about ference in the prevalence of burnout before
40 hours per week, giving them enough time and after the pandemic. This can occur due
to rest. However, this does not rule out the to differences in each study regarding the
possibility that other factors also influence number of respondents, the type of work of
the prevalence of this burnout. respondents, how burnout is measured, and
Jurnal Psikiatri Surabaya | Vol. 12 No. 2 November 2023 119
 Simbolon - Burnout and Contributing Factors

factors related to burnout. In addition, we A person with a heavy workload is

only found one article from the articles we at risk of experiencing burnout by 2.4 times
analyzed that discussed burnout in special- [12]. The workload that a person will accept
ist doctors, namely gastroenterologists [24], must follow the physical, cognitive, and
so we could not compare the prevalence of skills possessed to prevent fatigue due to an
burnout and burnout-related factors between inappropriate workload.
specialist doctors. Working time
Burnout is identified when the MBI question- Long working time (≥70 hours/week) in-
naire yields significant emotional tiredness creases a person’s risk of experiencing burn-
(score 27), depersonalization (score 10), or out by 1.26-3.83 times compared to someone
low self-satisfaction (score 40), as another with less than 70 hours of work time [26].
illustration of how variations in techniques Another study of 457 doctors in Shanghai
can affect the occurrence of burnout [11]. (China) showed that working hours working
The General Oldenburg Burnout Inventory more than 60 hours/week increases the risk
(OLBI) questionnaire, which includes tired- of burnout by 4.54 times.36 High working
ness and disengagement dimensions (similar hours can reduce rest time and increase ex-
to depersonalization in MBI), is used by oth- posure to stress at work [33].
ers in this study [25]. Work environment
Factors that influence it in healthcare work- A bad work environment can increase
ers the risk of burnout by 2.4 times [12]. Harm-
Age ful environments include limited medical
Young age (≤ 40 years) is associat- equipment, inconsistent soundproof privacy
ed with an easier burnout of 3.17-3.51 times rooms, unpleasant room color lighting, bath-
compared to someone with an older age room access, inadequate room temperature,
[17,26]. Conceptually, the older a person is, and so on [34]. Theoretically, an adequate
the more mature a person is in dealing with and pleasant work environment (including
various situations. access to workplaces, facilities, and rooms)
Gender can positively impact a person’s psychology,
The relationship between gender and such as stress relief.
burnout is still much debated. In some stud- Stress level
ies, it is known that burnout occurs more Someone who experiences stress at
frequently in women than men [21,30,31], work tends to burn out by 4.41 times [24].
while in other studies, the opposite results Stress that lasts a long time and continuous-
are found [26,32]. This difference can be due ly causes a person to experience emotional
to differences in the system/culture in the exhaustion. If a person is unable to manage
workplace, for example, determining sched- stressful conditions, this can lead to distress,
ules or workloads that are more amplified in unable to cope with stressful situations, and
men. tends to run away from problems.
Work experience history Spirituality/beliefs
Work experience history (> 10 years) Spirituality shows that someone ac-
is associated with burnout. This is suspected tive in worship activities tends to be less
as a result of more extended working peri- likely to experience burnout than someone
ods, which will make work feel like monot- who is not actively worshiping [15,35,36].
ony and can trigger boredom and feeling Someone with spirituality believes that his
unenthusiastic. This can lead to a desire to work is beneficial and contributes to the
stop working even though the work involves good of himself and others. Other. The in-
responsibility for one’s life. dividual will also have a deep relationship
Workload with fellow human beings [37].
120 Jurnal Psikiatri Surabaya | Vol. 12 No. 2 November 2023
 Simbolon - Burnout and Contributing Factors

Limited access to psychological services Contact with COVID-19 patients

Access to psychological services is essential Since the COVID-19 pandemic,
to diagnose psychological problems so they there has been an increase in burnout among
can be treated and managed appropriately. healthcare workers. The prevalence of burn-
The limitations of mental health services out is higher in healthcare workers in inten-
can impact the increasingly chronic mental sive care units (ICU) and healthcare workers
health of healthcare workers, so it is feared who are residents and nurses. COVID-19
that it can reduce the performance of health- causes healthcare workers to face life-threat-
care workers’ services in health facilities ening situations, exposure to the virus, and
[28]. an even greater workload. Apart from that,
Level of education COVID-19 also creates concern for health-
A high level of education is also as- care workers who can transmit the virus to
sociated with the occurrence of burnout. This their families [38].
is presumably because the higher a person’s Seniority
educational status and seniority, the greater Seniority in this article differs from
the responsibility. In addition, when faced age. Seniority here means the status of health
with a case with alarming results, high ex- workers, for example, a junior resident with
pectations of someone highly educated will an advanced resident (senior). Residents at
tend to result in the individual experiencing the initial level (junior) experience burnout
disappointment [29]. more easily (1.48 times) than those at an ad-
Marital status vanced stage. This is presumably because ju-
The relationship between burnout nior-level residents have a higher workload
and marital status is still being debated. This and lack experience and responsibility than
is because there are still several studies that senior residents [25].
get different results. This difference could Type of job
exist due to sociocultural and demograph- Between surgical residents, there are
ic differences among the respondents. For differences in the prevalence of burnout be-
example, conceptually, someone who has a tween types of surgical specialties such as
partner who can provide social support gen- general surgery, orthopedics, urology, and so
erally tends to experience burnout rarely; on on in various studies [11]. Regarding com-
the other hand, for example, a woman who is parisons between healthcare workers, no
working and married may manage to burn- significant differences were found between
out more easily because, in some areas, it general practitioners and other healthcare
may require that a woman must also be able workers regarding the incidence of burn-
to become a mother for her children and to out [29]. Another study by Štěpánek et al.
be a good wife to her husband [11]. (2023) found that doctors more often expe-
Leadership management rience emotional exhaustion and depersonal-
Bad leadership management, for ex- ization than non-physician healthcare work-
ample, for the head of the room, can burden ers. In another study, different results were
healthcare workers in carrying out their du- obtained. Namely, nurses experienced high-
ties. Leaders who do not have the skills to er emotional exhaustion than doctors [39].
match each member’s ability with the ap- Working more than usual or a lot
propriate workload will tend to make their (more than 70 hours per week), having a
members experience burnout. In addition, heavy workload, experiencing a lot of stress
the instructions of the head of the room, who at work, and having a hostile workplace are
does not have good communication skills, all factors that are frequently linked to this
tend to make their members experience con- burnout. Of course, these risk factors must
fusion and stress at work [19]. be immediately addressed to avoid burn-
Jurnal Psikiatri Surabaya | Vol. 12 No. 2 November 2023 121
 Simbolon - Burnout and Contributing Factors

out’s negative impacts. The consequences of der, marital status, type of work, workload,
this burnout may be detrimental to you and stress level, length of service, number of
those around you. Reduced job satisfaction, hours worked per week, and level of educa-
absenteeism, cynicism, negative emotions, tion. This may be caused by the limitation
anxiety, substance misuse, isolation, and the of the research done in the pandemic era,
collapse of social and family ties all affect which cannot show the actual circumstanc-
oneself. The impact on other people may re- es. In several studies before the COVID-19
sult in a lack of professionalism in handling pandemic, additional factors such as religi-
patients, which results in subpar patient care, osity, work environment, and organization-
unhappy patients, and malpractice in taking al structure leadership were found. In con-
[2]. trast, during the COVID-19 pandemic, there
Physical, mental, and emotional exhaustion were other risk factors, namely the risk of
brought on by burnout can make someone transmission of COVID-19, educational
lose their enthusiasm and drive for work. background, and access to psychological
The longer the work experience is, the high- services. It is essential to recognize the caus-
er the possibility of them becoming exhaust- es of burnout in healthcare workers so that
ed. The COVID-19 pandemic caused more appropriate treatment may be found to ad-
workload and working time, which can be a dress these causes and lower the occurrence
source of stress. The existence of burnout in of burnout in this population.
health workers can increase risk factors for
mental illness such as depression [40]. Col- Conflict of Interests
laboration between different parties, includ- The authors have no conflicts of interest to declare.
ing clinical management or hospital man- Fundings
agement where healthcare workers work, is None
necessary to combat burnout in healthcare
workers. We arrange for the placement of References
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