Burnout Syndrome Associated with Nurses' Quality of Life During the Covid-19 Pandemic

Ana Zakiyah*, Duwi Basuki

Nursing Management Department, Bina Sehat PPNI University, Jawa Timur 61363, Indonesia

*Corresponding Author's Email: ana_ppni@yahoo.com

ABSTRACT

Background: COVID-19 cases that occur in Indonesia are accompanied by high mortality, which leads nurses as one of the frontlines to experience burnout syndrome and have an impact on reducing the quality of life of nurses. This study aimed to determine the relationship between burnout syndrome and the quality of life of nurses during the COVID-19 pandemic. Methods: This study was correlational with a cross-sectional approach. The population was 269 nurses working in health services in East Java and was obtained by incidental sampling. The quality of life of nurses was measured by the Short Form Health Survey 36 (SF 36), which consisted of 36 question items, while the level of burnout syndrome was measured by the Maslach Burnout Inventory-Human Service Survey, which consisted of 22 questions. Results: All nurses had experienced burnout syndrome in varying degrees. The nurse burnout rate was generally low at 163 (60.6%), and the quality of life of nurses was typically good at 252 (97.3%) and a small percentage at 17 (6.3%). The spearman rho p-value analysis <0.05 showed a significant relationship between burnout syndrome and nurses' quality of life. Conclusion: Life balance allows nurses to be able to balance work and can improve the quality of life. Nurses can use a variety of methods to cope with burnout syndrome and improve their quality of life.

Keywords: Burnout Syndrome; Quality of Life; Covid-19; Pandemic

INTRODUCTION

The COVID-19 pandemic in Indonesia has put the healthcare system under tremendous pressure. This is due to the rapid demand to adapt to health needs during the COVID-19 pandemic (Sayılan, Kulakac, & Uzun, 2021; FKUI, 2020). The number of death cases increased along with the increase in cases, sometimes reaching more than 1,000 deaths in a single day. The Ministry of Health reported 40,427 new cases on Monday, July 12, 2021. The total number of COVID-19 cases in Indonesia has reached 2.567 million people. The number of active cases or patients requiring treatment has reached 380,797 people. This has caused concern in hospitals as they are overwhelmed with the surging COVID-19 patients. The Bed Occupancy Rate (BOR) in hospitals has reached 77%. This number was a record compared to the previous edition, which was still in the range of 30 thousand every day (Hastuti, 2021). The perceived threat of COVID-19 has helped in explaining the level of burnout among nurses and moderating the relationship between social support and the workplace. Excess workload, limited infrastructure, human resources, workplace social support, inefficient use, personal protective equipment, uncertain diagnosis criteria, and psychological stress have significantly explained burnout (Manzano García & Ayala Calvo, 2021; Thambidurai et al., 2019; WHO, 2020). Nurses must be willing to leave family and friends to serve others at the expense of the most precious possessions of time and life. A study suggested that ICU nurses experience significant burnout, with a high prevalence of psychosomatic symptoms closely associated with it, highlighting the need for enhancing the work environment through increased support and empowerment of the nursing staff (Ali & Eissa 2018). A few fell because they were infected with COVID-19, and many died. The number of nurses is dwindling, and the minimal number requires nurses to stand by all day to carry out humanitarian duty calls. In addition, complete personal protective equipment (hazmat) is used while on duty. To tackle the psychological symptoms experienced by nurses, it is essential to assess and measure the extent of burnout, depression, and anxiety while also examining possible factors that contribute to these issues (Li et al., 2023).

Burnout is more than stress due to excessive fatigue, cynicism, and low self-efficacy as a result of chronic work tension. Burnout is formed due to the imbalance of job demands with individual abilities derived from the inability to use effective coping against existing stressors (Rosa et al., 2020; Manzano-García & Ayala-Calvo, 2021). The COVID-19 pandemic has exacerbated the reality of the work environment, which can cause nurse burnout rates to grow exponentially as hospitals ask nurses to work under potentially extreme conditions. Wan et al. (2020) found that nurses in Wuhan experienced mild and moderate burnout. According to Bruyneel (2021), two-thirds of ICU nurses are at risk of burnout related to working conditions during the first wave. Jalili et al. (2021) also mentioned that 326 people (53%) experienced moderate burnout levels in the subdimension of emotional fatigue, and burnout was low in the depersonalization aspect (Sayilan et al., 2020).

The results of the burnout survey showed that one-third of paramedic staff had high levels of emotional exhaustion, more than two-fifths had low achievement rates, and one-third had high levels of depersonalization (Yacout, Mohamed, & El Sherbini, 2021). Sham et al. (2017) stated that nurses have experienced high burnout, with 83.3% of respondents experiencing depersonalization and 42.5% experiencing reduced personal achievement. FKUI (2020) stated that 83% of health workers have experienced moderate and severe burnout syndrome. 41% of health workers have experienced moderate and severe emotional fatigue, 22% have lost empathy, and 52% lack confidence. Burnout does not occur in the short term. Still, it gradually increases, creating long-term problems such as feelings of hopelessness, distress, and failure at work, and it also impacts the quality of human life (Bakker et al., 2000).

The quality of human life is an individual's perception of their position in the cultural context and value system relating to goals, expectations, standards, and attention. It is a broad concept influenced complexly by a person's physical health, psychological state, level of independence, social relationships, and personal beliefs (WHO, 1997). Until now, research on the quality of life measurement that has been carried out has focused more on measuring the quality of life of high-risk groups of people, such as the elderly, patients with pacemakers, cancer patients, and other patients who are in emergency positions. Without realizing it, health workers are among the high-risk groups of people, especially nurses, who are currently one of the most numerous health workers and are at the forefront of dealing with COVID-19. Based on this description, researchers observed burnout syndrome and the quality of life of nurses during the COVID-19 pandemic.

METHODOLOGY

Research Design

This study used a cross-sectional approach to determine the relationship between burnout syndrome and nurses' quality of life.

Population, Sampling, and Sample

All nurses working in health services in East Java, Indonesia, the sampling type used was accidental sampling. Researchers determined samples based on chance; they could take samples of anyone they met without prior planning to be given questionnaires, so 269 respondents were obtained.

Data Collection

Questionnaires were distributed through Google Forms to reduce the risk of transmission. The instrument for measuring burnout syndrome using the Maslach Burnout Inventory-Human Service (21) consisted of three elements: physical and emotional fatigue, depersonalization, and decreased personal accomplishment (Maslach and Jackson, 1986). Nurses' quality of life measurements using Short Form Health Survey 36 (SF 36) consisted of physical function, physical limitations, emotional control, energy fatigue, mental health, social functioning, bodily pain, and general health.

Statistical Analysis

Descriptive statistics were used for univariate analysis of respondents' characteristics, the frequency distribution of burnout syndrome, and the quality of life of nurses. Referential statistics (nonparamatrices) were used, named Spearman's rank correlation coefficient', to test the relationship between burnout syndrome and nurses' quality of life. The significance level was set at 0.05 for the hypothesis.

Informed Consent

Informed consent was done online as a first step that respondents must approve before completing the questionnaire. All respondents were informed that their participation was voluntary, and confidentiality and anonymity were guaranteed.

Ethical Consideration

The ethical approval for this study was taken from Bangil General Hospital on 13th January, 2022 with reference number 445.1/ 003 /424.072.01/2022.

RESULTS

Table 1: Characteristics of Respondents by Gender, Marital Status, and Level of Education (N=269)

Table 1 showed that most of the respondents were female, with 196 respondents (72.9%). Nurses were mostly married, with 213 respondents (79.2%), and nurses with diploma level education were 137 respondents (50.9%).

Table 2: Characteristics of Respondents by Age and Length of Working (N=269)

*Normal distribution data (p>0.05)

Table 2 showed that the mean age is 34.3 years, with the youngest being 21 years and the oldest aged 57 years. The mean working time of the respondent is 8 hours, the minimum working time is 4 hours and a maximum working time of 15 hours.

Table 3: Burnout Syndrome (N=269)

Table 3 showed that nurses who experienced burnout syndrome suffer with depersonalization and decreased personal accomplishment in the low category with decreased balanced percentages of 74.3% and 73.6%.

Table 4: Quality of Life (N=269)

Table 4 showed that the quality of life of nurses is generally in the good category especially in the aspect of physical function 97.4%, but in the aspect of emotional limitations the bad category has the highest percentage of 25.3%.

Table 5: Relationship of Burnout Syndrome and Nurse Quality of Life

** Correlation is significant at the 0.01 level (2-tailed)

The analysis showed that there was a relationship between burnout syndrome and the quality of life of nurses.

DISCUSSION

The results showed that all nurses experienced burnout syndrome during the COVID-19 pandemic, but at varying rates. The COVID-19 pandemic caused a sudden surge in inpatient admissions in hospitals as a consequence of an increase in workload. The safety of health workers in hospitals is a significant concern. Exposed to several hours of work per day with infected patients, nurses are at risk of experiencing some problems that lead to physical and psychological impairment (Bellanti et al., 2021). Burnout results from long-term exposure to job demands and stress, including physical, mental, and emotional syndromes that include pessimism about oneself and work, decreased desire to do work, and increased turnover (Canu, 2021).

Nurses with less understanding, work experience, and confidence in caring for COVID-19 patients experience burnout more often. An increase in workload, a decrease in self-confidence in self-protection, and a decrease in work safety when treating patients are associated with an increase in fatigue (Galani, 2021). The high incidence of burnout among nurses is recognized as a threat to nurses, patients, and hospitals. Burnout is associated with decreased mental and physical health of healthcare workers, lower quality of care, threats to patient safety, low patient satisfaction, reduced productivity, high turnovers, and increased healthcare costs (Zare et al., 2021). In the domain of physical and emotional exhaustion, nurse burnout rates were low: 120 (44.6%), moderate: 91 (33.8%), and fair: 58 (21.6%). Emotional exhaustion is the side that expresses the physical and emotional fatigue experienced as the basis and start of burnout syndrome. Emotional burnout is mostly related to work stress. The result of emotional exhaustion is unresponsiveness to the people they serve. Also, his work feels like torture because he thinks he cannot bear the following days and always feels tense. Emotional exhaustion is characterized by prolonged physical, mental, and emotional fatigue. When workers feel fatigued, they tend to be emotionally and physically overextended. They cannot solve problems, feel tired despite having enough rest, and lack the energy to do activities (Leiter, Bakker, & Maslach, 2014).

The depersonalization domains were at a low level of 200 (74.3%), medium at 61 (22.7%), and quiet at 8 (3%). Depersonalization is an attitude that shows harsh or rude behavior, negative behavior, and indifference to others. Some people exhibit behaviors such as losing motivation and enthusiasm due to getting further away from themselves and their work, being indifferent to the people served, and showing negative and hostile reactions. In the domain of low self- achievement (personal accomplishment), most were at a low level of 198 (73.6), medium 64 (23.8%), and moderately 7 (2.6%). Self-achievement becomes a dimension of self-evaluation in burnout syndrome. A person tends to evaluate themselves negatively and think they are not making progress. Poor self-evaluation results also indicate decreased self-achievement, low interpersonal relationships, a loss of enthusiasm, reduced productivity, and a lack of adaptability. The decrease in self-achievement is also characterized by helplessness, feeling that all the tasks given are heavy. When nurses think ineffectively, they tend to feel inadequate. Every job feels difficult and unworkable, and self-confidence is lacking (Aydin Sayilan, Kulakaç, & Uzun, 2014).

Burnout syndrome is closely related to hospital working conditions, but personal factors influence burnout. Previous research has shown that demographic factors such as age, gender, having children, and marriage are determinants of burnout (Zare et al., 2021). The study's results averaged the age of nurses at 34.3 years. They were in the age category of young adults. Age is related to the level of maturity of individuals. Workers more youthful than 30 years old will experience burnout at a higher rate than workers older than 30 years old. Naz et al. (2016) found that older nurses experience higher fatigue and stress than younger, unmarried nurses. Likewise, with gender, most female respondents were 196 (72.9%). A woman will experience a higher level of burnout than a man, and women often feel emotional exhaustion. According to Matsuo et al. (2021), 149 (22.6%) of 672 healthcare workers met the overall burnout criteria, which was more prevalent in women.

The marital status of respondents was mostly married at 213 (79.2%); a married person will experience burnout more easily. According to Alotni and Elgazzar (2020), married nurses have higher rates of burnout; marital status factors are associated with insight into social support; they may feel less emotional, care more about patients, and feel more satisfied with their profession. The COVID-19 pandemic had a significant influence on the work of nursing professionals in intensive care units (ICUs) (Meneguin et al.,2023). In the education level data, most nursing diplomas were obtained, as many as 137 (50.9%). Education states that the higher the level of education, the higher the level of burnout compared to workers with lower education. An effective management system can help improve positive attitudes and human relationships. Therefore, nursing managers must plan strategies to reduce burnout syndrome and increase resilience (Rivas et al., 2021). The delivery of COVID-19-related information and educational interventions on personal protective equipment and motivation in the workplace is necessary to reduce the mental burden. Confidence in using personal protective equipment and reduced fear of getting infected can be considered factors that can prevent burnout (Matsuo et al., 2021).

The results showed that the quality of life of nurses during the COVID-19 pandemic after the second wave was generally good, and a small part was bad. The health-related quality of life scale's physical and mental health components were used as key outcomes in the study. Individuals with strong beliefs about their abilities can actively solve problems and adapt better to complex situations. A person with this ability reacts positively to stress, uses resources better, and can more calmly accept the consequences of problems (Penacoba et al., 2021).

Age is one factor affecting the quality of life (Inocian et al., 2021). The study's results averaged the nurses' age in the age category of young adults. That younger age was a significant factor in the emotional exhaustion and depersonalization of nurses, but they are more responsible for the consequences of their actions. Individuals in the adult age group are more active, have broader coping strategies, and can see problems from various perspectives (Ahmad et al., 2017; Galaiy & Kinross, 2020). Suryavanshi et al. (2020) found that 87% of health workers who provide COVID-19 care directly, with 43% treating >10 patients per day, obtained a low quality of life (89.45%). Moderate to severe depression and anxiety are associated with an increased risk of low quality of life. Health workers may experience social isolation, stigma, and fear, which contribute to a decrease in quality of life. This condition challenges nursing managers to pay more attention to work schedules, arrangements for health workers, workload, and decreased quality of life (Suwandi et al., 2021). Improving communication between fellow health workers and support through the completeness of adequate facilities and infrastructure can be a concern in nursing services.

Burnout syndrome correlates with the quality of life of nurses during the COVID-19 pandemic. In line with Widayati (2020) and Rebeiro et al. (2021), there is a moderate relationship between QNWL and the incidence of burnout syndrome. Low burnout rates can improve a nurse's quality of life. Burnout, as a physical and mental syndrome that results in physical fatigue and emotional exhaustion, hurts the work and lives of others. Poor quality of life is strongly associated with decreased performance, burnout, and early retirement. Work-life balance provides an opportunity for nurses to be able to balance work and commitment in life. The study was conducted in 12 European countries, with workload influencing the nurse's practice environment and burnout. Stressful situations negatively affect the quality of life of care nurses. The three MBI factors and the four WHOQOL-BREF factors are significantly negatively correlated, indicating that high burnout leads to poor quality of life (Naz et al., 2016).

A nursing manager can manage burnout through psychological empowerment, and nurses can use a variety of methods of coping with burnout syndrome and improving quality of life. Nurses will have the skills of developing their own individual resources, which have contributed to the development of the nurse's social competence to build emotional bonds with others, respect for dignity and empathy with patients, and effective communication between colleagues (Kupcewicz, 2020; Permarupan et al., 2020). Relaxation, work environment improvement, and social media's role are important. Practising meditation or yoga and working on hobbies (for example, reading, watching movies, and listening to music) can reduce stress. Proper training in COVID-19 management, adequate isolation wards, adequate rest and good nutrition, and sufficient supplies of personal protective equipment Likewise, the role of the media can help build awareness by providing correct information (Suryavanshi et al., 2020). Areas of

improvement in the quality of life of clinical nurses can prevent burnout and increase positive feelings toward working with patients infected with COVID-19, as further engagement can lead to trauma and fear and can affect nurses' ability to provide good care. In addition, it is responsible for meeting the needs and expectations of nurses (Bit-lian et al., 2022). Prospective intervention strategies can improve control over predictors that directly influence the quality of life (El-Soud et al., 2020). Strategies such as resistance training and Mindfulness-Based Stress Reduction (MBSR) can be used as interventions in coping with stress that may be beneficial for nurses to adjust to job roles and responsibilities. Nurses can use religious beliefs as a coping strategy. Early detection of nurse saturation levels can avoid burnout syndrome in the long term (Sham et al., 2017; Munif et al, 2020).

CONCLUSION

Burnout syndrome was correlated with nurses' quality of life during the COVID-19 pandemic. Low burnout rates can improve a nurse's quality of life, and vice versa. Improvement in the nurse's quality of life can be brought about by preventing fatigue and increasing the nurse's positive feelings. Life balance allows nurses to be able to balance work, which can improve the quality of life.

Conflict of Interest

The author reported no conflict of interest in this research.

ACKNOWLEDGEMENT

The researcher would like to thank the appropriate Chairperson of Bina Sehat PPNI University, Indonesia, who has financed this research.

REFERENCES

Ahmad, S., Ishtiaq, S. M., & Mustafa, M. (2017). The role of socio-economic status in adoption of coping strategies among adolescents against domestic violence. Journal of Interpersonal Violence, 32(18), 2862–2881. https://doi.org/10.1177/0886260516635321.

Ali, S. A. O., & Eissa, A. K. A. (2018). Relation between burnout and psychosomatic symptoms among staff nursing in intensive care units. The Malaysian Journal of Nursing (MJN), 9(4), 20-28. https://ejournal.lucp.net/index.php/mjn/article/view/347/308

Alotni, M. A., & Elgazzar. S, E. (2020). Investigation of burnout, its associated factors and its effect on the quality of life of critical care nurses working in Buraydah Central Hospital at Qassim Region, Saudi Arabia. The Open Nursing Journal, 14, 190–202. https://doi.org/10.2174/1874434602014010190.

Aydin Sayilan, A., Kulakaç, N., & Uzun, S. (2020). Burnout levels and sleep quality of COVID-19 heroes. Perspectives in Psychiatric Care, February 2021. https://doi.org/10.1111/ppc.12678 .

Aydin Sayilan, A., Kulakaç, N., & Uzun, S. (2021). Burnout levels and sleep quality of COVID-19 heroes. Perspectives in Psychiatric Care, 57(3), 1231–1236. https://doi.org/10.1111/ppc.12678

Bakker, A.B., Killmer, C.H., Siegriest J, S., & Schaufeli,W.B. (2000). Effort–reward imbalance and burnout among nurses. J Adv Nurs, 31(4), 884–891. https://doi.org/10.1046/j.1365-2648.2000.01361.x .

Bellanti. F., Buglio, A.L., Capuano, E., Dobrakowski, M., Kasperczyk. A.,Kasperczyk, S., Ventriglio, A., & Vendemiale, G. (2021). Factors related to nurses' burnout during the first wave of coronavirus disease-19 in a university hospital in italy. International Journal of Environmental Research and Public Health, 18(10). https://doi.org/10.3390/ijerph18105051.

Bit-lian, Y., Woei-ling, T., Shahin, N., & Shuhaimi, B. (2022). Job satisfaction and burnout among registered nurses in a private hospital. The Malaysian Journal of Nursing, 13(January), 3–11. https://doi.org/10.31674/mjn.2021.v13i03.001 .

Bruyneel, A. (2021). Prevalence of burnout risk and factors associated with burnout risk among ICU nurses during the COVID-19 outbreak in French speaking Belgium. Intensive and Critical Care Nursing, 65. https://doi.org/https://doi.org/10.1016/j.iccn.2021.103059 .

Canu, G.I.,Marca, S.C., Dell'oro, F., Balazs,A., Bergamaschi, E., Besse, S., Baichi, R., Bislimovska, J., Bjelajac, A.K., bugge, M., Busneag, C.L., Caglayan, C., Cernitanu, M., Pereira, C,C., Hafner, N.D., Droz, N., Eglitte, M., Godderis, L., & Gundel, H. (2021). Harmonized definition of occupational burnout: A systematic review, semantic analysis, and Delphi consensus in 29 countries. Scandinavian Journal of Work, Environment and Health, 47(2), 95–107. https://doi.org/10.5271/sjweh.3935 .

El-Soud, F.A., Alhoraim.S., Alammar.A., & Alotaibi, R. (2020). Quality of life, self-rated health and social support among older adult in the Saudi community. The Malaysian Journal of Nursing, 11(January), 13–25. https://doi.org/10.31674/mjn.2020.v11i03.003 .

FKUI. (2020). 83% Tenaga Kesehatan Indonesia Mengalami Burnout Syndrome Derajat Sedang dan Berat Selama Masa Pandemi COVID-19. Berita UI. https://fk.ui.ac.id/berita/83- tenaga-kesehatan-indonesia-mengalami-burnout-syndrome-derajat-sedang-dan-berat-selama- masa-pandemi-covid-19.html .

Galaiya.R., Kinross. J., & Arulampalam (2020). Factors associated with burnout syndrome in surgeons: a systematic review. Annals, 102(6). https://doi.org/https://doi.org/10.1308/rcsann.2020.004.

Galani. P., Vraka. E., Fragkou. D., Bilali.A., & K. . (2021). Nurses burnout and associated risk factors during the COVID‐19 pandemic: Asistematic review and meta-analysis. Journal of Advanced Nursing, 77(8), 3286–3301. https://doi.org/10.1111/jan.14839 .

Hastuti, R. K. (2021). Covid-19 RI meroket, hari ini tembus rekor 40.427 positif. CNBC Indonesia. https://www.cnbcindonesia.com/news/20210712131638-4-260106/covid-19-ri- meroket-hari-ini-tembus-rekor-40427-positif.

Inocian, E. P., Cruz, J. P., Saeed Alshehry, A., Alshamlani, Y., Ignacio, E. H., & Tumala, R. B. (2021). Professional quality of life and caring behaviours among clinical nurses during the COVID-19 pandemic. Journal of Clinical Nursing, May, 1–13.

https://doi.org/10.1111/jocn.15937 .

Jalili, M., Niroomand, M., Hadavand, F., Zeinali, K., & Fotouhi, A. (2021). Burnout among healthcare professionals during COVID-19 pandemic: a cross-sectional study. International Archives of Occupational and Environmental Health, 1996. https://doi.org/10.1007/s00420- 021-01695-x .

Kupcewicz. E, and Jozwik. M. (2020). Role of global self-esteem, professional burnout and selected socio-demographic variables in the prediction of polish nurses’quality of life–a cross- sectional stud. Risk Management and Healthcare Policy, 13, 671–684. https://doi.org/10.2147/RMHP.S252270.

Leiter, M. P., Bakker, A. B., & Maslach, C. (2014). The contemporary context of job burnout. In Burnout at work (pp. 1-9). Psychology Press.

Li, Y., Fan, R., Lu, Y., Li, H., Liu, X., Kong, G., ... & Wang, J. (2023). Prevalence of psychological symptoms and associated risk factors among nurses in 30 provinces during the COVID-19 pandemic in China. The Lancet Regional Health–Western Pacific, 30. https://doi.org/10.1016/j.lanwpc.2022.100618

Manzano-García,G., & Ayala-Calvo, J. C. (2021). The threat of COVID-19 and its influence on nursing staff burnout. Journal of Advanced Nursing, 77(2), 832–844. https://doi.org/10.1111/jan.14642 .

Matsuo, T., Taki, F., Kobayashi, D., Jinta, T., Suzuki, C., Ayabe, A., Sakamoto, F., Kitaoka, K., Uehara, Y., Mori, N., & Fukui, T. (2021). Health care worker burnout after the first wave of the coronavirus disease 2019 (COVID-19) pandemic in Japan. Journal of Occupational Health, 63(1), e12247. https://doi.org/10.1002/1348-9585.12247 .

Meneguin, S., Ignácio, I., Pollo, C. F., Honório, H. M., Patini, M. S. G., & de Oliveira, C. (2023). Burnout and quality of life in nursing staff during the COVID-19 pandemic. BMC Nursing, 22(1), 14. https://doi.org/10.1186/s12912-022-01168-7

Munif, B., Oktaviana, S., & Wirawati, W. A. (2020). Effectiveness of mindfulness in reducing academic stress in nursing students : a systematic review. The Malaysian Journal of Nursing, 12(October), 119–124. https://doi.org/10.31674/mjn.2020.v12i02.016 .

Naz, S., Hashmi, A. M., & Asif, A. (2016). Burnout and quality of life in nurses of a tertiary care hospital in Pakistan. Journal of the Pakistan Medical Association, 66(5), 532–536. https://pubmed.ncbi.nlm.nih.gov/27183930/.

Penacoba, C., Catala, P., Velasco, L., Carmona-Monge, F.J., & Garcia-Hedrera, F.J. (2021). Stress and quality of life of intensive care nurses during the COVID-19 pandemic: Self-efficacy and resilience as resources. Nursing in Critical Care. 26(6). https://doi.org/10.1111/nicc.12690.

Permarupan, P. Y., Al Mamun, A., Samy, N. K., Saufi, R. A., & Hayat, N. (2020). Predicting nurses burnout through quality of work life and psychological empowerment: a study towards sustainable healthcare services in Malaysia. Sustainability, 12(1), 388. https://doi.org/http://dx.doi.org/10.3390/su12010388.

Rebeiro, E. K. A., dos santos, R.C., de Araujo-Monteiro, G.K.N. Brandao, B. M. L., da Silva, J.C., & Sauto, R.Q. (2021). Influence of burnout syndrome on the quality of life of nursing professionals : quantitative study. Psychiatric Nursing and Mental Health, 74(Suppl 3), 1–6. https://dx.doi.org/10.1590/0034-7167-2020-0298

Rivas, N., López, M., Castro, M. J., Luis-Vian, S., Fernández-Castro, M., Cao, M. J., García, S., Velasco-Gonzalez, V., & Jiménez, J. M. (2021). Analysis of burnout syndrome and resilience in nurses throughout the COVID-19 pandemic: A cross-sectional study. International Journal of Environmental Research and Public Health, 18(19). https://doi.org/10.3390/ijerph181910470.

Rosa, W. E., Schlak, A. E., & Rushton, C. H. (2020). A blueprint for leadership during COVID-19. Nursing Management, 51(8), 28–34.

https://doi.org/10.1097/01.NUMA.0000688940.29231.6f.

Sayılan, A. A., Kulakac, N., & Uzun, S. (2021). Burnout levels and sleep quality of COVID- 19 heroes. Perspectives in Psychiatric Care.

Sham, F., Munirah, S., Wahab, A., Rahim, E. A., Aimi, N., & Aizan, K. (2017). Burnout among nurses in clinical training centre, Selangor. The Malaysian Journal of Nursing, 9(October), 71–77. https://ejournal.lucp.net/index.php/mjn/article/view/436 . Accessed on 2nd February, 2023.

Suryavanshi, N., Kadam, A., Dhumal, G., Nimkar, S., Mave, V., Gupta, A., Cox, S. R., & Gupte, N. (2020). Mental health and quality of life among healthcare professionals during the COVID-19 pandemic in India. Brain and Behavior, 10(11), 1–12.

https://doi.org/10.1002/brb3.1837 .

Suwandi, F. R., Fahmy, R., Murni, D., Nelwati, N., Susanti, M., & Putri, Z. M. (2021). Analisis Hubungan Kualitas Kehidupan Kerja Perawat dengan Kualitas Hidup Dimasa Pandemi Covid- 19 di Rumah Sakit Umum Daerah M. Natsir. Jurnal Ilmiah Universitas Batanghari Jambi, 21(3), 1065. https://doi.org/10.33087/jiubj.v21i3.1710 .

Thambidurai, S., Gowthaman, P., Venkatachalam, M., & Suresh, S. (2019). Optik - International Journal for Light and Electron Optics, 19, 163865. https://doi.org/10.1016/j.jiph.2021.07.004 .

Wan, Z., Lian, M., Ma, H., Cai, Z., & Xianyu, Y. (2020). Factors associated with burnout among chinese nurses during COVID-19 Epidemic: a cross-sectional study. BMC Nurs, 21(51), 1–19. https://doi.org/10.1186/s12912-022-00831-3 .

Widayati, D. (2020). Quality nursing work life dan burnout syndrome pada perawat. Journal of Ners and Midwivery, 7(1), 123–129.

https://doi.org/http://jnk.phb.ac.id/index.php/jnk/article/view/535

World Health Organization (WHO) (1997). Measuring quality of life. The world health organization quality of life instruments. Geneva 1997.p 1-13. Geneva, 1-13.https://apps.who.int/iris/bitstream/handle/10665/63482/WHO_MSA_MNH_PSF_97.4.pdf?se quence=1&isAllowed=y .

Yacout, D.A.E.A., Mohamed, N.Y.,& El Sherbini, H. . (2021). Post-traumatic stress disorders and burnout syndrome among community paramedic staff. The Malaysian Journal of Nursing, 12 (January), 37–54. https://doi.org/10.31674/mjn.2021.v12i03.006 .

Zare, S., Kazemi, R., Izadi, A., & Smith, A. (2021). Beyond the outbreak of covid-19: Factors affecting burnout in nurses in Iran. Annals of Global Health, 87(1), 1-8, https://doi.org/10.5334/aogh.3190 .