Burnout and mental health problems among health care workers during second wave of Covid-19 pandemic: A hospital based cross sectional study

Abstract

1. Consultant Psychiatrist, Child and Adolescent Psychiatry Unit, Mental Hospital Lagankhel, Lalitpur, Nepal 2. Senior Nursing Officer, Dadeldhura Hospital, Dadeldhura, Nepal 3. Consultant Physician, Department Of Internal Medicine, Dadeldhura Hospital, Dadeldhura, Nepal 4. Director, nursing and social security, Department of health service, Kathmandu, Nepal 5. Consultant Orthopedic Surgeon, Department of Orthopedics, Dadeldhura Hospital, Dadeldhura, Nepal The symptoms of depression, anxiety and stress were found to be 31.3%,40.6 % and 14.6 % respectively.Doctors were 5.2 and 6 fold more likely to experience anxiety and depression respectively.The prevalence of personal, work, and client-related burnout were 43.7%, 31.3% and 14.6% respectively.Younger healthcare workers (HCWs) less than 27 years were 3.5 fold more likely to develop personal burnout.Healthcare workers who had worked for more than 100 hours/week were 5 times more likely to experience personal burnout.Doctors and nurses were 7.9 and 3.5 times more likely to develop work related burnout.Personal, work and client related burnout were significantly correlated with anxiety.

Work related variables
Majority of the HCWs were nurse (45.8%) and 9.4% were doctors.Majority of the HCWs had worked for less than 5 years (62.5%).Most HCWs were working in COVID ward (22.9%).Majority of HCWs had worked for 42 hours per week (Table 2)

Levels of burnout, depression, anxiety and stress
The mean (±SD) scores of personal, work-related and client related burnout were 46.00(±10.52),41.40 (±11.25) and 35.85 (± 11.49) respectively.Almost 13.5 % of the study sample were experiencing general burnout across all three domains.The scores for the subscales revealed that the  Cronbach's alpha coefficient for DASS-21 and CBI ranged from (0.78-0.91) and (0.85-0.87) respectively. 6,7ores for depression, anxiety, stress were calculated by summing the scores for relevant items 7 .The subscale scores for CBI were calculated by taking mean of the items in each scale.A general burnout is achieved by totaling the scores and calculating the mean.Total scores range between 0 and 100 and a score of 50 or more indicated burnout. 7After collecting data, analysis was done using SPSS 22.0.Chi -square test and multivariate logistic regression was used for inferential analysis.Spearman's rho was used to identify the correlations between CBI and DASS subscale.DASS subscale scores were used as continuous variables and merged into two group (Normal versus Mild-Extremely severe) and CBI subscales was also merged into (No burnout versus Burnout) using the cut off points provided in User's manual. 6,7A 95 % confidence interval was taken and P value less than 0.05 was termed as statistically significant. Bhattrai

Association between depression, anxiety and stress with other variables
Male HCWs were 4 fold (AOR=4.421,CI =1.364-14.34)more likely to experience stress as compared to female HCWs.Younger HCWS were found to have to higher proportion of depression, anxiety and stress but the difference between age and level of anxiety, depression and stress was not significantly associated.Doctors were 6 times more likely to develop depressive symptoms (AOR=6.00,CI=1.43-24.26and were 5 fold likely to experience anxiety symptoms (AOR= 5.27, CI= 1.31-21.09)as compared to other profession.HCWs working in COVID ward had more level of anxiety and stress but the association between level of anxiety and stress with department was not statistically significant (Table 5)

DISCUSSION
Epidemics have always been part of human life.The mental and physical health of HCWs are at particular risk. 8his study is the first to use CBI for measurement of burnout in Nepal and the first one assessing mental health of HCW's working in rural settings.Several studies have reported that during pandemics, burnout had been frequently reported among HCW'S which require immediate attention.9In this study the prevalence of personal, work-related and client related burnout was found to be 43.7%,31.2% and 14.6% respectively.This finding is similar to the study conducted in Malaysia by Roslan et al. 9 with personal, work and client related burnout with 53.8%, 39.1% and 17.4 % respectively.This finding is also supported by the study conducted in India and Australia. 10,11e present study shows that the prevalence of depression, anxiety and stress symptoms are 31.3%,40.6% and 14.6% respectively.[14] In our study the level of all three burnout were significantly higher in doctors and also has high prevalence of anxiety, stress among doctors.This might be due to increased working hours, limited doctors, low doctor patient ratio, high level of work related stress as compared to other HCW's.Doctors had to attend on-call everyday which might increases the level of burnout, depression in this study.Physicians are particularly vulnerable to experience burnout due to heavy workload and high level of work related stress. 15In the study conducted in Saudi Arabia showed HCWs with increased working hours was signifi-cantly associated with the increased rate of burnout. 16On contrary, the study conducted in other parts of the world showed that burnout, depression, stress and anxiety was more in nurses as compared to doctors. 4,11,13,14,17e present study reveals that younger HCWs had high level of burnout, depression, anxiety and stress as compared to the older age.9][20][21] Younger age group are more exposed to social media, which shares huge amount of information regarding the crisis and older HCWs have the ability to manage their stress as they are more knowledgeable regarding pandemic than younger HCWs. 22,23Ws working in COVID ward had significant work related burnout as compared to non COVID ward and also had high level of depression, anxiety and stress.[26] HCWs in COVID ward are especially vulnerable to mental health problems, including burnout, stress, fear, anxiety, depression and insomnia. 26 our study male HCWs had higher level of depression, anxiety and stress..Our findings indicate that not all HCWs are equally affected by COVID-19 pandemic.It was especially the doctors who are affected more during this COVID-19 pandemic.Findings can help to quantify staff support, staff need and tailored intervention.

CONCLUSION
We found the significant proportion of burnout, depression, anxiety and stress among doctors, younger HCWS and HCWs working in COVID ward.Furthermore having longer working hours assigned to treat patient with COVID-19 are strong predictor of psychological distress.We would like to recommend stratification of working hours for all HCW's and adequate staffing along with fulfilment of vacant posts in hospital taking care of COVID-19 patients.It is necessary to pay attention to mental health of HCWS combating the COVID-19 pandemic.Regular assessment of mental health is necessary as the pandemic continues to rise again.Keeping stable working team, improving communication, social support and providing clear guidelines are necessary to improve psychological well-being of HCWs.

Association between burnout with depression, anxiety and stress
All subscales of burnout were positively correlated with depression, anxiety and stress.All three subscales of burnout were significantly correlated with anxiety while work and client burnout was significantly correlated with stress Spearman's rho correlation ranging from 0 .26 to 0.34 (Table 6)

LIMITATION
This study is conducted in single hospital settings and the result cannot be generalized.Moreover relatively small sample size didn't allow in depth analysis.Another limitation could be self -reporting bias, depending upon interest level and mindset of the respondent.

Table 4 )
N et.al. Burnout and mental health problems among health Association between Burnout and other variables

Table 3 . Prevalence of burnout, depression, anxiety and stress by study group (n=96).Table 4 . Factors associated with burnout among healthcare workers (n=96). Table 5. Factors associated with depression, anxiety and stress among health workers (n=96).
*Signi cant at the 0.05 level ( 2-tailed) *Signi cant at the 0.05 Bhattrai N et.al. Burnout and mental health problems among health

Table 6 . Spearman's rho correlations between Copenhagen Burnout Inventory and Depression, Anxiety and Stress Scale
Correlation is signi cant at the 0.05 level(2-tailed) *Bhattrai N et.al. Burnout and mental health problems among health