key: cord-0858662-toe1hbys
authors: Tan, Benjamin YQ.; Abhiram, Kanneganti; Lim, Lucas JH.; Tan, Melanie; Chua, Ying Xian; Tan, Lifeng; Sia, Ching Hui; Denning, Max; Goh, Ee Teng; Purkayastha, Sanjay; Kinross, James; Sim, Kang; Chan, Yiong Huak; Ooi, Shirley
title: Burnout and Associated Factors Amongst Healthcare Workers in Singapore during the COVID-19 pandemic
date: 2020-10-05
journal: J Am Med Dir Assoc
DOI: 10.1016/j.jamda.2020.09.035
sha: bf1f5b07990b2df20e625ecc88d0b9858104052f
doc_id: 858662
cord_uid: toe1hbys

Objectives The strain on healthcare systems due to the COVID-19 pandemic has led to increased psychological distress among healthcare workers (HCWs). As this global crisis continues with little signs of abatement, we examine burnout and associated factors among HCWs. Design Cross-sectional survey study. Setting and Participants Doctors, nurses, allied health professionals, administrative and support staff in four public hospitals and one primary care service in Singapore 3 months after COVID-19 was declared a global pandemic. Methods Study questionnaire captured demographic and workplace environment information and comprised three validated instruments, namely the Oldenberg Burnout Inventory (OLBI), Safety Attitudes Questionnaire (SAQ), and Hospital Anxiety and Depression Scale (HADS). Multivariate mixed model regression analyses were employed to evaluate independent associations of mean OLBI-Disengagement and -Exhaustion scores. Further subgroup analysis was performed among redeployed HCWs. Results Among 11,286 invited HCWs, 3,075 valid responses were received, giving an overall response rate of 27.2%. Mean OLBI scores were 2.38 and 2.50 for Disengagement and Exhaustion respectively. Burnout thresholds in Disengagement and Exhaustion were met by 79.7% and 75.3% of respondents respectively. On multivariate regression analysis, Chinese or Malay ethnicity, HADS anxiety or depression scores ≥8, shifts lasting ≥8 hours and being redeployed were significantly associated with higher OLBI mean scores, while high SAQ scores were significantly associated with lower scores. Among redeployed HCWs, those redeployed to high-risk areas in a different facility (offsite) had lower burnout scores than those redeployed within their own work facility (onsite). A higher proportion of HCWs redeployed offsite assessed their training to be good or better compared to those redeployed onsite. Conclusions and Implications Every level of the healthcare workforce is susceptible to high levels of burnout during this pandemic. Modifiable workplace factors include adequate training, avoiding prolonged shifts ≥8 hours and promoting safe working environments. Mitigating strategies should target every level of the healthcare workforce including frontline and non-frontline staff. Addressing and ameliorating burnout among HCWs should be a key priority for the sustainment of efforts to care for patients in the face of a prolonged pandemic.

high SAQ scores were significantly associated with lower scores. Among redeployed HCWs, 27 those redeployed to high-risk areas in a different facility (offsite) had lower burnout scores 28 than those redeployed within their own work facility (onsite). A higher proportion of HCWs 29 redeployed offsite assessed their training to be good or better compared to those redeployed The first COVID-19 case was reported in Singapore on 23 rd January 2020 and by 3 rd April 42 2020, stay-at-home orders, locally termed "circuit breaker" measures, were instituted 43 whereby work-from-home arrangements were encouraged and schools and non-essential 44 services such as dining, retail and entertainment establishments were closed for about two 45 months. Non-urgent medical care was reduced wherever possible to redeploy healthcare 46 resources towards surge capacity and frontline units such as the emergency department, 47 inpatient pandemic and intensive care units 1 . Pandemics impose immense psychological burden on healthcare staff due to a mix of 68 workplace stressors and personal fears. A meta-analysis 9 showed that when comparing high 69 versus low risk exposure groups, the odds ratio for acute or post-traumatic stress (PTS) and Oldenburg Burnout Inventory (OLBI) and Hospital Anxiety and Depression Scale (HADS). 107 We grouped respondents by categories such as 1) HCW roles, 2) Sex, 3) Ethnicity, 4) 108 Redeployment outside primary roles, 5) Being tested for COVID-19, 6) Primary site of work, 109 7) Educational status and 8) Average duration of shift during the pandemic (compared to 110 routine 8-10 hour shifts during non-pandemic periods)

The OLBI is a 16-item validated tool to assess burnout 21 (Appendix C) covering two 121 dimensions i.e. Exhaustion and Disengagement. Disengagement refers to distancing oneself 122 from the objects and content of one's work while exhaustion refers to feelings of emptiness, Thus, a score of "1" is transformed to "0", "2" to "25", "3" to "50", "4" to "75" and "5" to 150 "100". A score of ≥75 and above is a "Percentage Agree" for that domain and a "Percentage 151 Agree Rate" is the proportion of respondents with a "Percentage Agree". Conversely, a score 152 of ≤50 represented "Percentage Disagree". Table 2 and Figure 1 ). Mean HADS Depression and Anxiety scores were 5.7 and 6.9 On mixed model regression analysis with institution as random effects (Table 2) surrogate for workplace safety environment during a pandemic among other variables and did 258 so at a timely juncture of four months after Singapore's first case and two months after 259 instituting major changes to the public health system to combat COVID-19. Questionnaire) was highest in unwilling HCWs followed by HCWs without objections and 303 lastly willing HCWs. Hu et al. 58 , however, noted that while staff dispatched voluntarily from 304 elsewhere to Wuhan had significantly lower emotional exhaustion scores, they had 305 significantly higher depersonalisation scores compared to those assigned there. Finally, the 306 strong association between high SAQ Percentage Agree Rates and low OLBI scores highlight 307 the importance of a supportive work safety environment in reducing burnout [9] [10] [11] 13 . Coping strategies should be taught during and in between pandemics to reduce the onset and 331 effects of burnout as a continual priority in sustaining patient-care efforts. J o u r n a l P r e -p r o o f 

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