Predictors of burnout in nurses working in inpatient rooms at a public hospital in Indonesia

Introduction This study aimed to determine the factors that predict the incidence of burnout in nurses who work at the Public Hospital of Tangerang Regency in Banten, Indonesia. Methods A cross-sectional design was used in this study. Participants were selected from eight inpatient wards at the Public Hospital of Tangerang Regency (hereinafter termed the hospital) by using a proportionate stratified random sampling method. A total of 133 nurses working in the inpatient wards were recruited. Data were collected using a questionnaire on nursing work schedule setting policy, daily log questionnaire for workload, competency scale and the Maslach Burnout Inventory scale for nurse burnout. Stepwise multiple linear regression was used to analyze the data. Results For most respondents (54.1%), the nursing work scheduling policy was appropriate, whereas the average score of nurse workload was 80.42 with SD ± 0.49, and the competency of most nurses was appropriate (64.7%). The average score of nurse burnout was 17.48 with an SD ± 0.50. Work schedule policy and workload were significant burnout predictors, accounting for 87.2% of the variance (Adjusted R2=0.872) in burnout among nurses who worked in the hospital's inpatient wards. Conclusion Nursing work schedule setting policy and workload were the main factors that led to burnout in nurses working in the inpatient wards. This issue can be overcome by regulating the workload in a balanced manner and applying appropriate policy in the nurse work schedule.


Introduction
Burnout is a psychological problem and includes emotional and physical fatigue caused by excessive stress that can last a long time.

This problem is often found in nurses who work in hospitals in
Indonesia. Some studies show that burnout is still a problem for nurses with a high incidence, including Ramdan and Fadly's research in which most of the nurses (56%) working in the AH Samarinda Hospital in East Kalimantan Province, Indonesia, experienced burnout [1]. Likewise, Yumi's study of the incidence of burnout at Tangerang Regency Public Hospital found that 48.0% of nurses suffered from high burnout and the other 52.0% from low burnout. Therefore, managing burnout well is very important to improve nurses' performance in nursing care. Burnout management can be well implemented if various factors that cause burnout are identified, including predictors of burnout incidents in nurses working in inpatient wards at the hospital, such as nursing work schedule policy, nurse workload and competency factors. Several studies have been conducted to determine the factors that predict the incidence of burnout in nurses, such as the Tawale et al. research, indicating a correlation between work motivation of nurses and tendency for burnout in which greater motivation is associated with less burnout.
Additionally, Indraswari and Ningrum's study revealed a connection between hardiness and burnout in which stronger character was associated with less burnout in nurses. Sari established a relationship between workload, demographic factors (age, marital status), length of service, locus of control, self-esteem and burnout syndrome among working nurses, but the results also disclosed no relation between sex, education level and nurse burnout. Widya kusumastuti and Fauziah concluded that interpersonal communication relates to burnout in nurses, whereas Ramdan and Fadly found a relationship between sex, employment status, workload, support, leadership and nurse burnout but found that age had no correlation with nurse burnout [1].  Table 3 shows that workload and work scheduling policy working hours, as nurses must remain at the ready and standby even during breaks and off-hours. Conversely, if the work shift schedule adjustment policy improves the nurses' satisfaction, burnout incidents could be averted [6].
Fatigue is a functional reaction from the center of consciousness, namely, the cerebral cortex, which is influenced by two antagonistic systems, namely, the inhibitory system (inhibition) and the driving system (activation) [7]. The inhibitory system is in the thalamus and can reduce human ability to act and cause a tendency to sleep.
According to Nurmianto, the occurrence of fatigue is due to static muscle loading so that blood flow to the muscle decreases, which results in lactic acid accumulation. In addition, it is also due to muscle load that is not evenly distributed in particular tissues. If in a long A consequence of working with a shift system is that it often involves long working hours or long work shifts. Kontz [8] recommends that working hours should not exceed 12 hours a day or 55 hours a week.
The results show that workers who work more than the recommended work time in a day but with less than the maximum working time for the week are preferred because they have many advantages such as more time spent with the family, fewer consecutive night shifts and longer holidays. However, the impact caused in terms of safety is that it can increase the number of accidents, reduce work performance and increase errors. Studies that have been conducted using subjective or objective measurements of fatigue generally support that there is a relationship between long working hours and the incidence of fatigue.
This association can be seen in the research in Japan by Levy [9] who reported that the number of weekly working hours of workers in Japan increased by ¼ from male workers with working hours >60 hours per week. Other studies have shown that judging from long working hours, there is an association between fatigue and health problems such as karoshi-"dead due to long working hours". Karoshi is a syndrome of heart attacks such as stroke and myocardial infarction.
The type of work shift consists of four main types of working hours.
They include daily work, which is the work period between 7am and 6pm, and permanent shift, which is a work system in which routine work schedules are followed or are the same every day. Permanent shift is divided into 3 types, namely, morning shift (6am -2pm), afternoon shift (2pm -10pm) and night shift (10pm -6am). Rotating shift is a work system in which there is variation between several shifts. The 2-shift system (morning and evening or evening and night) is usually used, although there are also those who use a 3-shift rotation system (including all three). Roster work or flexible rotating shift is another type of work shift. In arranging work shifts, things that need to be considered include the length of work in one shift, many shifts done before rest days, many rest days in one week, whether there is an increase in working hours or overtime, the length of rest used between shifts, length of rest during the shift, and whether the work schedule is regular and predictable. Work shift settings can affect the incidence of fatigue or stress. Workers with morning shifts and night shifts often feel sleepy and tired during shifts. This effect is because their circadian rhythm is disturbed. Night shift workers are forced to sleep during the day even though the circadian rhythm forces workers to stay awake during the day. Therefore, sleep time is shorter. Additionally, morning shift workers also have short sleep time because they are forced to leave early to go to work, which can make them tired quickly during work [8].
Kontz [8] states that one of the main reasons a person experiences fatigue is insufficient rest. This factor can result from working at the wrong time (shift work) or long working hours. Work requires the deployment of energy and the use of body organs in a coordinated manner. By its nature, work is anabolic, which is the breakdown or use of parts of the body to function. In fatigue, the nervous system is primarily functioning using its sympathetic component. Such a situation cannot occur continuously, and a break that gives the body the opportunity to recover is needed. Then, the rest is catabolic, which allows recovery in the body. In the labor law, rest periods include the following: rest between working hours, at least half an hour after working for 4 hours continuously, and the rest period does not include working hours and weekly breaks at least once a day for 6 working days in a week or 2 days for 5 working days in a week. Annual break, at least 12 working days for 6 working days in a week or 10 working days for 5 working days in a week, after the worker has been employed for 12 (twelve) months continuously; and rest properly to perform the obligations/fulfill worship according to his/her religion.
Establishing a good rest time especially for heavy work reduces the occurrence of illness and absenteeism. Experience shows that short breaks are often better than a long break. Research shows that establishing the appropriate rest time has a positive impact on productivity.
This study's findings are consistent with the Winwood et al. study, which examined the relationship between work fatigue and division of work shifts. They found out that the more shift work the workers do, the more severe the level of fatigue they experience [10]. The authors observed the frequency of shift work as an independent variable associated with work fatigue, including both physical and mental aspects; it is a long phase of energy deficiency that can lead to a decrease in workers' functional capacity [11]. Workload was distinguished as the second strongest factor in predicting the indigestion and irritability [14,15]. Similarly, the work environment also contributes to 73% of burnout [16]. In contrast, too little workload where repetition of motion occurs can lead to boredom and a sense of monotony. Tedium in regular daily work caused by too few tasks or jobs yields a lack of attention to work, potentially endangering workers [17].
In general, the relationship between workload and work capacity is influenced by a variety of factors that are very complex, both internal

What is known about this topic
• Incidence burnout is an indicator to manage workload and work shift scheduling policy in the hospital; • The strategy of hospitalization to improve burnout is to manage workload and work shift scheduling policy; • Evidence shows that the workload and work shift scheduling policy is predictors of burnout.

What this study adds
• The presence of burnout in nurses as a whole in the study area shows the importance of health for nurses; • The presence of variations in the incidence of burnout in nurses in hospitals shows the magnitude of the challenge of the control programmes; • Workload and work shift scheduling policy fluctuations can affect the incidence of burnout for nurses.