An exploration of burnout among hospital first-line managers in Indonesia during the COVID-19 pandemic

Background

The COVID-19 pandemic remains the focus of current global problems, especially in the world of health. Nurses, the largest fleet in handling COVID-19 (57% of all caregivers), experience significant professional, social, and psychological challenges with unique and unprecedented conditions (Duncan, 2020; Poortaghi et al., 2021; Rothan & Byrareddy, 2020; WHO, 2020). The burnout experienced by nurses before the pandemic increased as psychological pressure increased during the pandemic. The March-April 2021 survey found that 53% of health workers experienced at least two of the four symptoms of mental health disorders, namely PTSD (post-traumatic syndrome disorder), anxiety, distress, and despair, even when taking the initiative to commit suicide (Bryant-Genevier et al., 2021). In Indonesia, a study found that 52.5% of nurses experienced high burnout (Marpaung et al., 2020). The nursing profession is vulnerable to mental problems because their work is related to the continuation of human life (Wang et al., 2020) (Havaei et al., 2021).

Nurses, including first-line managers, have experienced high demands and complex problems during the COVID-19 pandemic caused nurse, including first-line managers, experienced burnout. The burnout experienced by executives and nurse managers is different. Managers’ burnout is due to their duties and responsibilities in managing the organization, nurses’ burnout is due to their duties as care providers to patients (Kelly et al., 2019; Johnson et al., 2020; Remegio et al., 2021). Several studies have shown that burnout is felt not only by clinical nurses, but also by nursing managers. Research conducted by White (2021) and Raso (2021) proved that as a result of the pandemic, 83% of nursing managers experienced mental stress, which increased due to the pandemic. In a crisis such as the current one, managers must dynamically use situational management and flexibility. Despite their problems, nursing managers with a strong presence in the field are good role models for the remaining staff (Poortaghi et al., 2021; Rosa et al., 2020; Yau et al., 2021).

There are many ways to handle burnout, but choosing the right strategy must be adapted to individual needs. According to Dall'Ora, Ball, Reinius, and Griffiths (2020), burnout management strategies can vary based on the symptoms they cause or can be adjusted to the organization's ability to carry out management. To date, research exploring nurse managers' experiences in dealing with the pandemic is still rare. A study of nurse managers conducted by White (2021) revealed that nurse managers experienced burnout during the pandemic. Handling burnout in first-line managers requires a deep understanding of the phenomenon in the first-line manager. Therefore, research is needed to explore the symptoms of burnout in nurse managers so that appropriate interventions can be provided. Based on this phenomenon, researchers are interested in exploring burnout among first-line managers during the COVID-19 pandemic in hospitals that are COVID-19 referral centers.

Methods

Results

Twelve first-line managers from two hospitals participated in this study. In general, participants were aged 32-54 years, female and male, with work experience as a nurse of 11-35 years and experience as a first-line manager of 4 months-7 years. All participants were married. The educational level of the participants was D3 and they had a bachelor's degree in nursing. However, in the interviews, it was discovered that several participants were currently studying for a bachelor's degree in nursing and a master's degree in nursing. There were variations in work units; there were participants who were first-line managers working at the Emergency Room, Children's inpatients, adult inpatients, NICU-PICU, and HCU-ICU; some were specifically for COVID-19, and some were not specifically for COVID-19. During the pandemic, both hospitals implemented a first-line manager rotation system. However, in this study, several participants were never rotated to the COVID-19 treatment section, so the variation was that they had been in the COVID-19 room and never been in the COVID-19 room. The thematic analysis of the collected data revealed three themes: 1) unpreparedness, 2) Impacts on well-being and 3) resilience. These three themes reveal the critical meaning of first-line managers’ experience of burnout experiences (Table 1).

Discussion

This study found that first-line managers experienced burnout while performing their roles and functions during the COVID-19 pandemic. According to Maslach and Leiter's theory, the symptoms of burnout consist of 3 dimensions: emotional exhaustion, depersonalization, and reduced personal accomplishment (Dall’Ora et al., 2020). The unpreparedness of various parties, especially hospital management and the community, to face the pandemic was the primary stressor for first-line manager burnout. Burnout impacted the psychological and physical well-being of participants. This shows that the dimensions of burnout are fulfilled by first-line managers, except for a decrease in self-achievement due to the resilience of the first line managers.

The COVID-19 pandemic has become a very complicated issue for first-line managers because of their lack of experience in dealing with this issue. Even though pandemics have occurred previously, COVID-19 has been different because the virus spreads quickly and can be deadly(Rosa et al., 2020). Hospitals face a high demand for providing services immediately. The first-line managers had to ensure that the service ran while prioritizing patients and staff safety (Middleton et al., 2021; Yau et al., 2021). Staffing and equipment constraints were the most significant obstacles in the early stage of the pandemic, which were experienced not only by the participants but also by various nursing institutions (González-Gil et al., 2021; Liu et al., 2020). The unpreparedness for various resources obstructs work performance and motivation (Batubara et al., 2020). If the work demands cannot be met immediately, it will cause first-line managers to experience burnout due to problems that still need to be resolved, even lingering beyond the workplace into their personal lives. This means that emotions and fatigue are felt throughout the day.

The experience with the COVID-19 pandemic shows that hospitals must be able to mitigate disease disasters. Law No. 17 of 2023 mandates that dealing with disease outbreaks be the responsibility of health services (Presiden RI, 2023). As part of risk management, the pandemic mitigation program must be implemented with a planned, budgeted, monitored, and reported program on an ongoing, systematic, logical, and measurable basis (Kementerian Kesehatan, 2022). Pandemic mitigation simulations should be carried out periodically, similar to other emergency code simulations, such as the blue and red codes.

The public's reaction during the observed early phase of the pandemic shows unpreparedness. Adverse reactions show this unpreparedness; it could even be said to be excessive, with the stigma spreading. This unpreparedness associated with a lack of information about how to deal with COVID-19, coupled with mass media reports about the deaths of many people and restrictions in public areas, which makes conditions even more tense (Ramaci et al., 2020). The first-line managers experienced the impact of the community's reaction. First-line managers received the most complaints from patients and families because of restrictions on access to meet patients and various restrictions in the hospital area. The public stigma against health workers in close contact with COVID-19 causes first-line managers to experience unpleasant reactions. This condition made them anxious about interacting with the environment outside the hospital. Psychological pressure occurs not only at the workplace but also from the outside workplace (Bryant-Genevier et al., 2021).

This study found that the burnout of first-line managers impacted emotional well-being, such as anger, annoyance, disappointment, sadness, stress, tiredness, and fear. This was related to emotional exhaustion in the burnout dimension. This happens because the stress felt by participants is higher than their burnout. The same findings were also found among medical workers in Minnesota, where burnout was only the tip of the iceberg of the deep stress felt by the participants (Britt et al., 2017). The first-line manager tries to carry out their interpersonal, decisional, and informational roles to the maximum, but circumstances such as unsupportive policies and limited resources make carrying out the part of the first-line manager a source of stress (Navinés et al., 2021; Wihardja et al., 2019; Yau et al., 2021). It was also found that women had more forms of emotional expression than men, and were more expressive, such as crying and various bodily expressions. This statement supports previous research that states that burnout is higher in women than in men, especially in women who are married and have children (Acosta-Ramos et al., 2021; Gupta et al., 2021; Lai et al., 2020; Rusca Putra & Setyowati, 2019; X. Zhang et al., 2021). Acosta-Ramos et al. (2021) and Rusca and Setyowati (2019) stated that women's vulnerability to burnout is related to their social lives and work outside the hospital, especially as housewives. Women's burnout is related to their positions as mothers and wives(L. Zhang et al., 2020).

First-line manager burnout also has an impact on the physical condition. Some participants complained of a lack of sleep, body fat, and hypertension, and some even ended up being infected with COVID-19 due to fatigue. Research conducted by Gupta et al. (2021) stated that burnout can stimulate the autonomic nervous system (ANS), which modulates the physiological stress response; therefore, stress can cause changes in a person's physical health status and even cause cardiovascular disease. This condition is also associated with perceived sleep disorders, in which stress can cause sleep difficulties (Wang et al., 2020).

This study was conducted after approximately two years, with two waves of the COVID-19 pandemic in Indonesia. The results show that the participants had good resilience in facing COVID-19. All participants were able to use adaptive coping mechanisms when facing pandemics. Coping strategies include acceptance, sharing, solitude, diversion, and spirituality. The coping strategies most frequently used by participants were acceptance and spirituality. These two strategies were used by participants even before the pandemic, but these strategies have become very honed due to the pandemic. The reception coping developed by the first-line manager was related to adapting the first-line manager to the need for more information on handling services for COVID-19 patients. Spirituality coping is related to religion; one adheres to the first-line manager. The findings support previous research stating that nurses' abilities are usually exposed to burnout conditions, they are used to develop several adaptive coping strategies to deal with various unpleasant situations (Shiu et al., 2021).

This study found that while carrying out their duties as the first-line manager during the COVID-19 pandemic, the first-line managers received a lot of support such as work support, emotional support, and material support from inside and outside the workplace. Support from outside the workplace comes from friends, donors, and family, both immediate and extended. This support can be blessings or permission, understanding, prayers, food, being listened to, and not being forgotten. Participants received work support from the same first line manager, nurse staff, supervisor, and doctor. The support provided to first-line managers in the workplace includes assistance in problem-solving, emotional encouragement, and material aid such as incentives and food. Several participants have mentioned that solidarity arises in their workplace because of the shared feelings of destiny and resilience in confronting the same adversary, namely, the COVID-19 pandemic. From this study, we can learn that managers need to improve and maintain this work climate because the work cohesion that has been built will increase job satisfaction and also has an effect on nurses' burnout (Penconek et al., 2021; Rusca Putra et al., 2021).

The attitude of hospital management, including first-line managers, in handling the pandemic reflects a transformational leadership style. Several studies have recommended that managers needed to prevent burnout should embody a transformational leadership approach (Kodama & Fukahori, 2017; Wei et al., 2020). The first-line manager came down to support and help to solve problem in their ward or unit. The supervisors of the participants have been giving out rewards, both material and psychological, although some people complained about the timing of getting the rewards. It's important to pay attention to rewards from the hospital management because they make nurses happier with their job, which can help reduce their burnout (Putra et al., 2021). The hospital management where this study was conducted has implemented a strategy to address staff burnout by using rotation and sharing one positive thing. Sharing positive things helps people focus more on the good, so unpleasant experiences can be avoided. Thus, management strategies are the easiest, do not require high costs, and can be used quickly (Nining et al., 2021; Tawfik et al., 2019).