Success Story Sri Lanka's COVID-19 Response Takes a Different Turn: Healthcare Workers' Burnout Impact

The COVID-19 pandemic made many countries respond quickly to suppress the transmission of this virus, strict restrictions on the entry of countries were carried out to successfully suppress transmission, Sri Lanka was successful in handling the initial pandemic. However, it lasted for a while, the policy of relaxing social restrictions made the population uncontrollably infected, and limited personnel made the workload and duration of work shift heavy. length of service plays a role in the burnout of Sri Lankan hospital health workers. This study aims to determine the effect of length of service and duration of work shifts on the incidence of Burnout among health workers during the COVID-19 pandemic in Sri Lanka. The method used an Observational Study based on datasets taken crossectional related to the incidence of burnout in health workers during the COVID-19 pandemic in Sri Lankan hospitals. Using the Copenhagen Burnout Inventory (CBI). The results obtained Length of Service has a significant effect on Personal Burnout, Work related burnout, Client related burnout, while the duration of work shifts has a significant effect on work-related burnout, insignificant on Personal Burnout and Client Related Burnout of Health workers in large hospitals in Sri Lanka during the COVID-19 pandemic


INTRODUCTION
The emergence of the COVID-19 pandemic worldwide continues to gradually and consistently increase; the total number of accumulated cases until 3 February 2023 reached 754,018,841 people, with a death toll of 6,817,478 (World Health Organization, 2023). Coronavirus disease 2019, or COVID-19, was initially reported in the city of Wuhan, China, on December 31, 2019, reported as pneumonia of unknown cause, the increase in the number of patients increased to 44 infected patients in 3 days and continued to be reported to have increased and spread infection throughout the world, making the World Health Organization (WHO) set it as a Pandemic on February 11, 2020, and named the virus SARS-CoV-2 and the name of the disease Coronavirus Disease 2019   (Burhan et al., 2020). In addition to the high spread rate, the symptoms caused by people infected with COVID-19 have a fatal impact because they attack the respiratory system, including fever of more than 38 degrees and severe shortness of breath, and are exacerbated in patients with comorbidities such as old age, history of heart disease, and history of chronic obstructive pulmonary disease (Burhan et al., 2022).
The spread of the COVID-19 virus quickly to 4 continents indicates a very high infectious rate. The first three reported cases of COVID-19 in Europe on January 24, 2020 (Stoecklin et al., 2020). the first case in America on January 20, 2020, (Bergquist et al., 2020), the first case in Australia on January 20, 2020 (Cook et al., 2020), the first case in Southeast Asia was reported from Thailand on January 13, 2020 (Chu et al., 2022), Moreover, the first case in South Asia was reported on February 15, 2020, in India and Sri Lanka (Khan et al., 2021).
Each country's initial response and handling are different due to many factors. However, it is clear that the more alert the country is to carry out preventive restrictions and strict monitoring related to preventing the spread of the virus entering the country, the better it will be in suppressing the spread of the virus among the population of the country (Wang et al., 2020).
Many countries have responded quickly in suppressing the number of transmissions of the COVID-19 virus at the beginning of the pandemic by imposing strict restrictions on the country's entrances both through ports, airports and also interactions between residents to successfully reduce the number of transmissions of the COVID-19 pandemic in their country, one of which is Si Lanka, this country imposed strict restrictions on all entrances to the country, especially air and sea routes on March 19, 2020, and carried out isolation and quarantine for migrants and residents who were suspected of carrying the COVID-19 virus because this country is an archipelago separated from other South Asian regional countries. As a result, the country became one of the keys to Sri Lanka's success in handling the initial COVID-19 pandemic. The success in suppressing the spread only lasted until June because, with the emergence of new variants of the COVID-19 virus and government policies to relax social restriction rules and the condition of the government preparing for general elections in the country in August 2020. The rate of virus transmission is increasing uncontrollably and is exacerbated by the illegal entry of COVID-19-infected migrants into the country from India. These various factors have led to an increase in the number of patients being treated and an increase in the workload experienced by health workers in the country.
A sudden increase in patients with a limited number of health workers makes the workload with normal working shift duration heavier. As well as the influence of internal factors such as age, gender, external factors, Length of Service, work unit, and work shift length also plays a vital role in the possibility of burnout in hospital health workers in the country. The high spread of viral infections and the need for intensive treatment of infected patients, as well as education and efforts to reduce the spread rate, make health workers who are at the forefront in dealing with the COVID-19 virus have significant responsibility and are vulnerable to psychological impacts in carrying out their duties, such as stress and anxiety. (Hanggoro et al., 2020).
The prevalence of psychological impact on health workers in a study that examined 80 studies involving 18 Asian countries found that health workers experienced depression as much as 34.61%, stress at 31.72%, anxiety at 34.81%, insomnia at 37.89%, and post-traumatic stress disorder 15.29% (Norhayati et al., 2021). Exposure to stress at work, in particular, can have a positive impact in the form of eustress or positive stress that can improve work performance, increase concentration, and provide additional energy, provided that it is experienced for a limited time. However, if experienced for a long time, it can turn into distress, a maladaptive response that makes emotions very negative or the opposite of eustress, leading to Burnout Syndrome. Burnout syndrome is a condition that occurs as a result of an imbalance in handling personal stress and work-related stress that causes physical and emotional exhaustion (Sasidharan & Dhillon, 2021). Burnout condition itself the assessment according to Kristensen, is assessed in three aspects (Personal Burnout, Work Related Burnout, and Client Related Burnout).

Participant characteristics and research design
The participants in this study were health workers working in 8 major hospitals in Sri Lanka. The design of this study was an observational study based on a secondary dataset taken cross-sectionally about health workers and the incidence of burnout during the COVID-19 pandemic in Sri Lankan hospitals. The burnout dataset in covid 19 Health care personnel contains 583 respondent data working in 8 large hospitals in the country of Sri Lanka related to burnout which is divided into three domains: Domain 1 Personal Burnout (Personal Burnout), domain 2 Burnout due to Work (Work Related Burnout) Burnout due to Work (Work Related Burnout), and domain 3 Burnout due to Clients (Client Related Burnout) Burnout due to Clients (Client Related Burnout) which can be accessed at the following link : https://www.kaggle.com/datasets/lilyHourses21/burnout-incovid-19-healthcare-personnel Sample size, power, and precision The sample data comprised 583 health workers working at Colombo North Teaching Hospital, UHKDU, Colombo South Teaching Hospital, National Hospital of Sri Lanka Colombo, National Hospital Kandy, Anuradhapura Teaching Hospital, Ratnapura Teaching Hospital, Karapitya Teaching Hospital.

Instrument
The instrument in this study is to use the Copenhagen Burnout Inventory (CBI), which consists of 3 measurement dimensions: Personal Burnout, Work Related Burnout, and Client Related Burnout. This questionnaire is used to measure factors related to the occurrence of Burnout. The Copenhagen Burnout Inventory (CBI) questionnaire has been tested for validity and reliability with Croncbach's Alpha results of 0.906 for Personal Burnout, 0.765 for Work Related Burnout, 0.901 for Client Related Burnout, and 0.936 for Overall Burnout. (Piperac et al., 2021).

Data analysis
Data analysis uses univariate, bivariate, and multivariate analysis. Univariate analysis is an analysis that aims to describe the characteristics of respondents presented in the form of frequency and percentage distribution tables. In this study, the univariate analysis consists of Age, Gender, Department, and Profession as confounding variables and Length of Service and Duration of Work Shift as independent variables in this study, as well as Burnout (Personal burnout, Work Related Burnout, and Client Related Burnout) as the dependent variable.
Bivariate analysis This analysis is carried out on two related variables. This analysis is carried out after univariate analysis In this study using the chi-square correlation test. To determine the magnitude of the influence caused by the independent and dependent variables. In this study, bivariate analysis was carried out between the variables of Length of Service on the incidence of Burnout (Personal burnout, Work Related Burnout, and Client Related Burnout), as well as the Duration of Work Shift on the incidence of Burnout (Personal burnout, Work Related Burnout, and Client Related Burnout) in respondents in this study totaling 583 people from 8 hospitals in Sri Lanka.
Multivariate analysis is used to determine more than one independent variable to see the most dominant variable related to several variables and to find out whether the relationship between the independent and dependent variables is influenced by other variables in this study using class assumption analysis and multiple linear regression tests. From Table 1, it can be seen that most of the respondents were between 21-30 years old, totaling 384 people (65.90%). This shows that most employees are at a young and productive age. Most respondents are female, totaling 452 people (77.50%). This shows that women dominate most employees. Most respondents work in the Accident and Emergency

RESULTS AND DISCUSSION
Unit/Outpatient Department/ Emergency Treatment Unit/ Progressive Care Unit ICU, totaling 356 people (61.10%). This shows that most employees work in the ICU Unit.
From Table 1, it can be seen that most respondents work as Consultants totaling 1 person (0.20%), Doctors totaling 156 people (26.80%), Minor staff totaling 3 people (0.5%), who did not mention specific 2 people (0.3%) and did not want to mention a total of 1 person (0.2%), Nurses totaling 360 people (61.70%), Physiotherapists totaling 29 people (5%), Radiographers totaling 21 people (3.6%), Supportive staff totaling 10 people (1.7%). This shows that most of the employees sampled work as nurses. Most of the respondents who worked <5 years amounted to 402 people (69%). This shows that most employees have worked for less than 5 5 years. From Table 2 it can be seen that most of the respondents who worked <5 years amounted to 402 people (69%), who worked 5 -10 years, as many as 83 people (14.2%), who worked 10-15 years as many as 49 people (8.40%), and who worked> 15 years as many as 49 people (8.40%), this shows that some employees have worked for less than 5 years. Most of the respondents who worked < 48 hours per week amounted to 116 people (19.90%) who worked 48 -60 hours per week, as many as 199 people (34.10%), who worked 60-72 hours per week, as many as 87 people (14.90%), and who worked > 72 hours per week as many as 181 people (31%), this shows that most employees work 48 -60 hours per week.   Table 3, it is found that most respondents with a length of service for dimension 1 (personal burnout), namely respondents with a length of service of fewer than 5 years, the most are those who experience moderate burnout, totaling 184 people (31.6%), this is in line with research conducted by (Ayisi-Boateng et al., 2020) that employees with a length of service between 1 -9 years have an incidence of burnout mos, 2020) that employees with a working period between 1 -9 years have a moderate or moderate burnout incidence rate of 41.2%, which shows that the younger the working age also has a vital role in the high rate of personal burnout, this is also supported by research conducted by Pan et al (2022), which states that as many as 56.7% of employees who work for less than ten years experience moderate burnout.
Based on Table 3, it is found that respondents with a length of service for dimension 2 (Work Related Burnout), namely respondents with a length of service of fewer than 5 years, the most are those who experience moderate burnout, totaling 202 people (34.6%), this is in line with research conducted by Marić et al. (2022), who conducted research related to burnout in health workers during the COVID-19 pandemic which stated that there were around 53.5% of health workers experiencing moderate burnout and as many as 20.73% experiencing work-related burnout which shows that the younger the working age also has a vital role in the high rate of work-related burnout.
Based on Table 3, it is found that most respondents with a length of service to dimension 3 (Client Related Burnout), namely respondents with a length of service of fewer than 5 years, the most are those who experience moderate burnout, totaling 287 people (49.2%), this is in line with research conducted by Youssef et al, (2021), which states that there is a significant influence between workers who have worked for more than 10 years with lower rates of work-related burnout due to adaptation and willingness to accept their work so far in caring for patients. In line with the research of Marić et al (2022), which shows that 20.9% of the total health workers studied experienced Client Related Burnout, and 31.3% of the total health workers experienced moderate burnout during the COVID-19 pandemic. This shows that the younger the working age also has a vital role in the high incidence of burnout related to Client Related Burnout or, in this case, patients Based on table 4, it is found that respondents with Work Shift Duration on dimension 1 (personal burnout), namely respondents with a Work Shift Duration of 48 -60 hours, the most are those who experience moderate burnout, totaling 105 people (18%), this is in line with research conducted by Youssef et al, (2021), which states that there is a significant influence related to the incidence of personal burnout in health workers who work more than 40 hours per week on a sufficient scale, supported by research conducted by Chin et al. (2015), which states that the higher the shift working hours of health workers will affect sleep hours, the higher the duration of the work shift per week dramatically affects the quality of sleep hours and causes personal burnout, health workers who manage to sleep for seven hours or more, nurses who sleep less than six hours on weekdays have a higher risk of personal burnout compared to workrelated burnout and client / patient-related burnout and sleep duration on weekdays is inversely related to burnout onset. Supported by research conducted by Pan et al, 2022), which states that employees with longer work shifts have a vulnerability to the emergence of burnout events.
Based on Table 4, it is found that most respondents with Work Shift Duration on dimension 2 (Work Related Burnout), namely respondents with Work Shift Duration of more than 72 hours, are those who experience moderate burnout, totaling 121 people (20.8%). This is in line with research conducted by Youssef et al, (2021), which states that there is a relatively high rate of work-related burnout in health workers who work more than 50 hours per week. Chambers et al ( 2016) state that longer working hours are a risk factor for personal and work-related fatigue, but working more than 14 hours is a risk factor for work-related fatigue or work-related burnout. In line with research conducted by Youssef et al, (2021), which states that there is a significant influence on the incidence of client-related burnout in health workers who work more than 50 hours per week ranging from moderate to large scale. Moreover, in line with research conducted by Møller et al (2022), more than 50% of health workers who have been studied experience work-related burnout.
Based on Table 4, it is found that most respondents with Work Shift Duration on dimension 3 (Client Related Burnout), namely respondents with Work Shift Duration of more than 72 hours, the most are those who experience moderate burnout, totaling 155 people (26.6%). This is in line with research conducted by Youssef et al, (2021), which states that there is a significant influence on the incidence of client-related burnout in health workers who work more than 50 hours per week ranging from moderate to high scale, supported by research conducted by Nimer et al. (2021), that the duration of the work shift of 51-75 hours per week has a significant influence on the emergence of the average burnout incidence rate -on average, moderate burnout is obtained  5 shows that Length of Service has a negative and significant effect on Dimension 1 (Personal Burnout). This shows that the higher the length of service, the lower the incidence of personal burnout among health workers in Sri Lanka Hospital. This study is in line with research conducted by Rodd (2017), which shows that personal emotional exhaustion is closely related to the length of service and has a significant effect on the low incidence of burnout in individuals who have served longer in a job and are supported by individual abilities, to adapt and also mature age and the influence of family support. Moreover, in line with research conducted by (Pačarić et al., 2018) which states that there is a better ability to control personal emotional stress in workers who have more years of service than younger ones.
Based on table 5 shows that Length of Service has a negative and significant effect on Dimension 2 (Work Related Burnout). This shows that the higher the length of service, the lower the incidence of workrelated burnout in health workers in Sri Lanka Hospital. This research is in line with research conducted by (Dirican and Erdil, 2016) that long-term employees have emotional control, avoid engaging in counterproductive work behavior, and try to balance the two roles they play. In addition, employees are accustomed to situations and problems from the work environment and family that come simultaneously, and this is because long-term employees already have different interpretation patterns and strategies. To overcome this role conflict compared to employees who have worked a little.
Based on table 5 shows that Length of Service has a negative and significant effect on Dimension 3 (Client Related Burnout). This shows that the higher the length of service, the lower the incidence of Client Related Burnout among health workers in Sri Lanka Hospital. This research is in line with research conducted by Rodd (2017), which states that there is a negative correlation between length of service and the incidence of work-related burnout, namely the longer the working period or as years of experience increase, the level of fatigue decreases, one of which is work-related burnout, motivation in work and motivation to maintain a career is associated with lower levels of burnout. Spending time with spouse/family and maintaining self-awareness were the two career-sustaining behaviors found to have the most significant positive impact on the overall lower incidence of burnout.

Effect of Work Shift Duration on Personal Burnout, Work-Related Burnout, and Client-Related Burnout
Based on table 5 shows that the duration of the work shift has a positive and insignificant effect on Dimension 1 (Personal Burnout). This shows that the higher the duration of the work shift, the higher the incidence of personal burnout in health workers in Sri Lankan hospitals. This study is in line with research conducted by Dall'Ora et al (2015) which states that nurses who work shifts ≥12 h are more likely than nurses who work shorter hours (≤8) to experience fatigue in terms of emotional fatigue and also personal fatigue and longer working hours for hospital nurses are associated with adverse outcomes for nurses. Some of these adverse outcomes, such as high fatigue, can pose a safety risk to patients and nurses. Supported by research conducted by Youssef et al, (2021), which states that there is a significant influence on the incidence of personal burnout in health workers who work more than 40 hours per week on a reasonably large scale. There is a positive influence between the duration of the work shift and the incidence of personal burnout, especially for workers who have a regular division of work shifts but get a turn to work during the night shift, exacerbated if the division of shift work hours is uneven, this will have an impact on increasing the rate of fatigue drastically the emergence of insomnia due to short natural sleep hours which have an impact on the mental health of workers. However, some conditions make the increase in personal burnout rates not too high, such as morning and afternoon shift workers (Cheng and Cheng, 2017).
Based on table 5 shows that the duration of the work shift has a negative and significant effect on Dimension 2 (Work Related Burnout). This shows that the higher the duration of the work shift, the lower the incidence of Work-Related Burnout among health workers in Sri Lanka Hospital. This research is in line with research conducted by (Dall'Ora et al., 2015). Supported by research conducted by Cheng & Cheng (2017) states that only specific shifts, especially the morning shift, have a low level of burnout which has sufficient time to sleep in contrast to the night shift and long work shifts, affecting the emergence of burnout, nurse sleep quality and fatigue, the female gender is also positively correlated, significantly associated with work-related fatigue. Contrary to research conducted by Youssef et al, (2021), which states that there is a significant influence and positive influence related to the incidence of client-related burnout in health workers who work more than 50 hours per week from moderate to high scale.
Based on table 5 shows that the duration of the work shift has a negative and insignificant effect on Dimension 3 (Client Related Burnout). This shows that the higher the duration of the work shift, the lower the incidence of Work-Related Burnout among health workers in Sri Lanka Hospital. This study is in line with research conducted by Moukarzel et al ( 2019), Work shift duties have a significant relationship with personal fatigue, work-related fatigue, and clientrelated fatigue in this study. Other findings confirmed that nurses who work in emergencies have more fatigue, especially those who work long shifts or night shifts, compared to day shifts. Contrary to research conducted by Youssef et al, (2021), which states that there is a significant influence related to the incidence of client-related burnout in health workers who work more than 50 hours per week ranging from moderate to high scale.

LIMITATION OF THE STUDY
It is necessary to elaborate on factors other than the length of work and duration of work shifts, for example, starting from aspects of gender, age, support system, and work units in the hospital on burnout so that we have more and more other perspectives so that the right hospital management policy formula can be created, regarding the prevention of burnout in hospital employees, especially in extraordinary circumstances such as a pandemic.

CONCLUSIONS AND SUGGESTIONS
From the results of this study, it can be concluded, in general, that, Length of Service significantly affects the incidence of Burnout in the three dimensions of Burnout (Personal Burnout, Work related Burnout, Client related Burnout). In contrast, the work shift's duration significantly affects dimension 2 (work-related Burnout). However, it has no significant effect on dimensions 1 (Personal Burnout) and 3 (Client Related Burnout) in health workers in 8 major hospitals in Sri Lanka during the COVID-19 pandemic.
Based on Length of Service, the majority of employees who experience Personal Burnout, Work related Burnout, and Client Related Burnout are workers who worked for less than 5 years, and the majority experience Moderate Burnout in three dimensions (Burnout, Personal Burnout, Work related Burnout) on Health in 8 major hospitals in the State of Sri Lanka during the COVID-19 pandemic.
Based on the duration of work shifts in general, the majority of health workers who experience Burnout are those who work more than 72 per week and experience the dimensions of Work-related Burnout and Client Related Burnout, then followed by workers who work for 28-60 hours per week on the dimension of Personal Burnout, in Health in 8 major hospitals in Sri Lanka during the COVID-19 pandemic.
ACKNOWLEDGMENT As a researcher, I would like to thank all those who have provided motivation, support, and criticism during this research. Moreover, the University of Muhammadiyah Yogyakarta Hospital Administration Study Program is a place of learning and for providing the opportunity to conduct this research.
ETHICAL CONSIDERATIONS Funding Statement.
The authors received no funding from any entity for the work they submitted..

Conflict of Interest Statement
According to the author, there is no potential conflict of interest in the creation and publication of this work.
The research was conducted independently and carried out after observing developments due to the co-19 pandemic, which caused various effects, one of which was on health workers at the forefront