Systematic Review Factors Affecting Burnout Syndrome Among Nurses: A Systematic Review

Background: Burnout syndrome is due to the fatigue felt from work, both physically and mentally. Work fatigue experienced by the health care team, especially the nurses, can threaten patient safety. There needs to be actions or policies put in place to decrease the level of nurse burnout syndrome. Before setting the policies or actions, it is important to know the factors that affect the occurrence of burnout syndrome. The purpose of this paper is to analyze the factors that influence the occurrence and incidence of burnout syndrome. Method: The authors specified the topics and keywords used to search the literature, which in turn allowed for the seeking and obtaining of the appropriate literature criteria. Result: The search found 15 pieces of literature. There are several factors that cause burnout syndrome, but the most common factor in the working environment was the poor working conditions and motivation factors of nursing itself. Conclusion: Based on the results above, we can reduce burnout syndrome with modifications in the working environment or improving the nurse’s motivation through policies, dependent on the institution. ARTICLE HISTORY Received: Dec 26, 2019 Accepted: Dec 31, 2019


INTRODUCTION
Nursing is one profession that is not easy to do; one might say that it is rife with risks because it deals with the lives and safety of others, and even salvation itself. The magnitude of this workload could grow when not supported by the working environment, the health institution and the wages. Some of the policies are increasingly adding to the problem and the burden must be shouldered by the. nurse Not all immediately find a good coping system and not all of them have emotional intelligence; burnout syndrome can be the result of this (Giorgi et al., 2016).
Burnout syndrome is defined as the effect of fatigue that is both physical and mental which develops the concept of self-negativity, a lack of concentration and negative work behavior. High levels of stress in a nurse can be caused by exhausting work routines, the number of patients who have to be serviced and pressure from their superiors who sometimes add to the burden on the mind of the nurses so as to cause a decline in the performance of the nurses. The nurse's role is very important in the primary health care services in the hospital; a nurse must be able to adapt quickly to high pressure and they should not be in a state of confusion when providing the nursing service (Cheng, Meng, & Jin, 2015).
The consequences arising from burnout in the nursing field are very diverse, including emotional exhaustion, depersonalization and a loss of individuality. Practically, this can be seen in everyday nursing practices. One example is the length of the working hours (shift) that a nurse has as well as a large number of patients (Fang, 2017). The longer the working hours of the nurses, the more that the risk of an error or accident in the workplace will grow. In addition to resulting indirectly in the service of nursing itself, burnout can also lead to an impact on the personal life of each nurse. One of the research studies shows the impact of burnout against family conflicts. When elaborated on further, the conflict is caused by the dimensions of time, stress and changes in behavior. Therefore, there needs to be an action or regulation to minimize the occurrence of burnout itself.
Nurses in various countries have different levels of workload and responsibility. This difference can be influenced by the social, cultural, environmental and market orientation, and particularly regarding the patients themselves. Although different, some research suggests that there are always nurses suffering from burnout. In one of the articles, it set forth that referring to the nurses in China, 71% work more than 8 hours a day for 2 months ahead of reaccreditation and as many as 44% experienced severe saturation level (Guo et al., 2016).
There are many effects related to the incidence of burnout syndrome that affect the nursing service. Nursing discontent at work will be increased when it has triggered a decline in performance and an even higher turnover of nurses themselves. It is important to take actions to reduce the risk of the occurrence of events where burnout starts from.

MATERIALS AND METHODS
We chose to focus on burnout syndrome as the topic. Factually, this specific condition has been an unsolved problem in management nursing studies up until now. Furthermore, we determined some of the keywords used to find the literature, namely burnout syndrome, nursing stress and nursing workload. Qualified international journals were involved to provide some of the information including Scopus, Science Direct, Pro quest and SAGE with the articles having been published between 2014 and up to the 2019 with the topic of nursing and burnout as the limitations.
The search found 8,666 articles and 363 articles that were duplicates were removed; 8,203 out of the 8,303 were excluded by screening both the titles and abstracts. We found 100 articles. We shortened the list again to 15 using the type of study and the location of the research. From the articles chosen, they were classified based on the type of research, the subject of the research and the correlation between the factors affecting burnout syndrome and the incident of burnout syndrome. The respondents were healthcare personnel consisting of doctors and the nurses from several departments.

RESULT Study Methods
Based on all of the research reviewed, the number of samples totaled 15,857 respondents. The respondents were mostly nurses and a small portion were doctors. The respondents from other professions were found in the study in order to find a relationship between the level of intelligence and the level of burnout (Giorgi et al., 2016). The instruments used in these studies mostly consisted of the Maslach Burnout Inventory instrument as a measurement tool for the burnout level of the respondents in 11 articles. Following this, 4 articles used different instruments (Cheng et al., 2015;Fang, 2017;Khamisa, Peltzer, Ilic, & Oldenburg, 2017;Kim & Yeom, 2018b). All of the articles were descriptive cross-sectional studies. Burnout level is closely related to external factors, especially the working environment (Năstasă & Fărcaş, 2015) and work pressure (Lee & Ji, 2018;Mehrabian, Baghizadeh, & Alizadeh, 2018). High work pressure can cause stress and it can be used as an initial predictor of burnout (Akman, Ozturk, Bektas, Ayar, & Armstrong, 2016). Other external factors related to burnout are the factors of leadership and organizational trust towards the nurses and vice versa (Nwafor, Immanel, & Obi-Nwosu, 2015). Burnout levels can increase when the nurses are face with problems outside of work. The burnout level risk increases when experiencing problems within the family and this can decrease the level of support from the family (Fang, 2017). In some articles, the internal factors that affect burnout include job satisfaction. It is stated that if the nurses often fail or feel dissatisfied with the results that are carried out continuously, then they will be prone to burnout (Akman et al., 2016;Nwafor et al., 2015). The moral stress experienced by the nurses will also cause burnout (Fumis, Junqueira Amarante, de Fátima Nascimento, & Vieira Junior, 2017). When the nurses experience burnout, either directly or indirectly, this will have an impact on the quality of service provided to the patients (Cheng et al., 2015). Broadly speaking, all of the articles analyzed have been summarized in the following table. Outcomes Based on some of the investigations about burnout syndrome in 15 journals, we found that there are 9 dominant factors that influence the creation of burnout syndrome.

Work Environment
This is recognized as the biggest factor that predisposes an individual to burnout syndrome. There were 2 research studies that explained about the relationship between the environment and the incidence of burnout syndrome by Zang et al in 2013 and Ernold et al in 2011. A positive work environment will reduce burnout syndrome. On the contrary, a negative work environment will increase the incidence of burnout syndrome.

Emotional Intelligent
Intelligence is an absolute attribute for everyone to allow them to make good preparations to become a success in terms of survival in all aspects of their life. There is no exception for nurses in their work. Intelligence is divided into different parts including emotional, social and spiritual. In the research journal by Natasha et al in 2014, they sought to discuss the role of the influence of emotional intelligence toward burnout syndrome in health workers, especially those in the nursing field. From their study, it was found that a higher level of nursing emotional intelligence will make for an easier adaptation to accept pressure and their work burden. As a result, burnout syndrome risk can be avoided.

Distress Morality
It cannot be denied that the nurse's involve feelings and empathy in their work. This will appear when they see the patients in a painful condition, especially in an emergency and terminal condition. These cases can also be met in an Intensive Care Unit or a High Care Unit. Based on research that conducted by Furnis et al (2017) (Fumis et al., 2017) implies that ethical dilemmas are a big problem for the nurses who work at ICU or HCU. The failure to save lives in critical and terminal conditions sometimes will result in the morality burden predisposing the nurse to burnout syndrome risk.

Nurse Self-concept
The nurse's ability to recognize their self concept is very important. It is needed to face their hard daily duties and to cope with many patients problems with many different characteristics of their own. Nwafor et al in 2015 conducted research related to the nurse's self concept. His conclusion was that the better the nurse's self concept, the more it will reduce the possibility of them suffering from burnout syndrome.

Personal and Work Stress
Burnout syndrome may also appear to come from personal stress and work stress. In 2016, Khamisa et al researched into the co-relationships between personal stress and work stress when related to burnout syndrome. It is clearly that the results inform us that personal stress has more of an influence on burnout syndrome than work stress.

Nursing Organization.
The nursing organization has a strategic position to decrease the burnout syndrome risk. This institution improves the media for the peer group of the nurses to interact with each other starting at the local, regional, national and even international scale. Some of the research studies identified that the higher the level of trust that the nurse has toward the role of their professional institution, the more this will minimize the burnout syndrome risk.

Empowerment and Motivation of Nurse.
Motivation and empowerment are needed to maintain good performance and spirit to do well in the nursing job. There are two studies that explain that motivation has an important role when it comes to inducing good work performance and reducing the incidence of burn out syndrome. Furthermore, these studies also mentioned that a higher and stronger nurse motivation toward their duties will lower the possibility of them getting burnout syndrome.

The Role of the Institutional Leader.
The role of the leader in a professional institution and organization is very important. Every policy from the leader has the power to influence whether the organization is more conducive or not. It is a must to create good leaders to create a conducive work environment to minimize burnout syndrome. One study conducted in Seoul South Korea implied that there is correlation between the role of the leader and the incidence of burnout syndrome; better leaders will reduce the condition of burnout syndrome among the nurses.
Spiritual well-being. The spiritual well-being side means different things for each individual. This can be influenced by age where the level of burnout is higher when experienced by those of a younger age, of no specific gender and when concerning work experience where the nurses who work for under five years experience higher levels of burnout (Kim & Yeom, 2018a)

DISCUSSION
The causes of burnout can be broadly grouped into two, namely external and internal factors. External factors are the organizations or institutions where nurses work. Workplace organizations if specified can cover the work environment, workload, relationships with their leaders, coworkers, trust in the system in the organization and vice versa. External factors dominate the occurrence of burnout significantly but the external factors are relatively more difficult to modify. For the workload, the nurses individually cannot change or modify these factors. The workload itself can cover the tasks that must be done concerning both the main tasks and any additional tasks that add to their working hours (Fang, 2017).
There must be authority and power in changing what has become a burden and the main task of a nurse. Relationships in the work environment can involve both leaders with the nurses and between the nurses. A good leader will always provide reinforcement to their staff members, strengthening through motivation and giving assignments that are proportional and fair to all members. The research shows that empowering leaders have a negative correlation with burnout (Guo et al., 2016).
A fair assignment also avoids job stress. Job stress itself is associated with the occurrence of burnout (Mehrabian et al., 2018) (Wu et al., 2014). When the nurses experience a lot of division regarding their tasks, the possibility of the results being obtained will not be optimal. The results of the work not being optimal causes reduced job satisfaction. The job satisfaction figures can be influenced by a number of things, namely among them a sense of failure in carrying out the task as well as possible. This can also be caused by an imbalance between workloads and in the awards received by the nurses. Low job satisfaction values can be related to an increase in the incidence of burnout (Zhang et al., 2014), (Khamisa et al., 2017).
The next organizational factor is the relationship with their fellow colleagues, both between the nurses or between the nurses with other professionals. In one organization, there is a sense of fair competition, especially in certain scientific disciplines. The competition will be good if it occurs within certain limits. The competition will be negative if there are no rules governing the situation. Competition like this can lead to mutual dropping and even intimidation can occur. This intimidation also causes the work atmosphere to become uncomfortable and this can cause effects in the form of burnout (Giorgi et al., 2016). The external factors are the factors that can be controlled by the stakeholder in an organization. A good top manager will understand that burnout can affect the quality of the service providers' output. The quality of the output of a nurse's service is caring. So when the nurses experience burnout, it can be ascertained that this will affect the nature of caring concerning the recipient of the service, namely the patients (Cheng et al., 2015). It would be ideal if the top manager continually evaluates the state of the organization, especially the work environment, so then there is not a high level of burnout. The top manager is also expected to be able to make dynamic policies regarding a conducive work environment.
Burnout can also be caused by internal factors. From the articles reviewed, it was found that burnout was negatively correlated with emotional intelligence (Năstasă & Fărcaş, 2015), self-concept (Nwafor et al., 2015) and spiritual well-being (Kim & Yeom, 2018a). This means that the better the emotional intelligence, self-concept and spiritual well-being of the nurses, the lower the risk of burnout. In addition to these three factors, burnout is also correlated with moral distress but the relationship between them is positive. To minimize this risk factor internally, it can be said to be an individual responsibility. The top manager is only supportive and facilitates the policies produced.

CONCLUSION
Exhaustion and fatigue are common. This condition can generate burnout syndrome and it is the cause of the decreasing work performance of the nurse. Based on some of the research studies, there are many factors related to burnout syndrome, namely the work the environment, emotional intelligence, moral distress, self concept, communication ability, massive work load, the role of the professional organization, the role of the leader and motivation and empowerment. From all of the factors above, the work environment and motivation were the dominant factors that influence the incidence of burnout syndrome among the nurses. It is a must to create a work environment that is more conducive and to keep up the internal motivation for the nurse to eliminate burnout syndrome. The study results show that spiritual intelligence strengthened the beliefs and personality of the nurses.