Middle East Respiratory Syndrome (MERS) is a respiratory disease that can result in death. It was first reported in September 2012 in Saudi Arabia and then spread throughout the world in 2015 [1]. South Korea had the second highest number of MERS cases in the world (n=186) and 38 people died [2]. During an outbreak of an infectious disease, healthcare workers (HCWs) are easily exposed to intense psychological responses. Thus, burnout is an important factor to consider during such events because it results in HCWs detaching themselves from work and performing at a suboptimal level [3,4]. Burnout is a state of physical and emotional depletion that results from persistent exposure to stressful working conditions [5]. This state consists of exhaustion, which is associated with feelings of emptiness, being drained, and a desire to rest, as well as the experience of disengagement, which results in cynical behavior and distancing oneself from work [6]. Cimiotti et al. [7] emphasized that reducing burnout is an important factor when fighting infectious disease in acute care facilities.

Considerable research has assessed burnout in HCWs. For example, Edwards et al. [8] suggested that burnout in HCWs is affected by organizational factors such as increased workload, time pressures, safety issues, role ambiguity, lack of supervision, and reduced resources. In addition, individual factors such as physical illness, personality, coping strategies, and job attitude also play an influential role [9-11]. Maunder et al. [12] assessed burnout in HCWs during the 2003 outbreak of Severe Acute Respiratory Syndrome (SARS) and found that perceived adequacy of training, support, and an adaptive coping style are protective against burnout.

However, few studies have investigated burnout during or after a MERS outbreak. Kim and Choi [13] examined burnout after MERS in terms of job stress caused by MERS, fear of MERS infection, hospital resources for the treatment of MERS, and support from family and friends. Although they found that job stress, poor hospital resources, and poor support from family and friends explained 47.3% of burnout, they did not examine whether personal strength or coping could prevent burnout or how experiences at the time of the incident and perceptions about epidemic disease impact it. Thus, we invested the proportion of HCWs that suffered from burnout (i.e., engagement and exhaustion) during the 2015 outbreak of MERS and the protective and/or risk factors associated with it (i.e., engagement and exhaustion).

We found that 65.5% of HCWs reported disengagement and 79.5% reported exhaustion during the 2015 MERS outbreak. In addition, disengagement was associated with lower levels of purpose and hope, the perception of higher job risk, and exposure to media whereas exhaustion was associated with lower levels of purpose and hope, a lower level of perceived control, and the perception of higher job risk. However, receiving MERS education did not have a significant effect.

It is important to note that the majority of participants in the present study experienced burnout during the outbreak. The rate of burnout was similar to that observed in emergency nurses after the outbreak although the present sample included various job types, including doctors, pharmacists, and technicians [13]. We also found that, among these groups, nurses reported the highest level of burnout and that women had a higher level of burnout than men. This is in contrast to the findings of Maslach and Jackson [19], who reported that men are slightly more vulnerable to burnout than women. It is possible that there were more female nurses than females in the other groups and thus future studies should determine whether high levels of burnout are more affected by sex or job. Nonetheless, our findings suggest that nurses should be a priority of interventions aimed at reducing burnout.

Of the personal strength variables, purpose and hope were the most powerful protective factors against both exhaustion and disengagement. This suggests that people who have purpose and hope can bear hardships and cope well with disastrous situations, which is consistent with previous findings. For example, Youssef found that employees with hope report higher levels of job satisfaction, work happiness, and actual performance [20]. Similarly, Sherwin et al. [21] examined occupational burnout among nurses in chronic care rehabilitation units and found that a higher level of hope is significantly associated with lower burnout. Therefore, during an outbreak of epidemic disease, setting attainable purposes and committing to those purposes could aid in the prevention of burnout in HCWs.

We also found that perceptions about MERS were an important variable predicting HCW burnout, particularly in terms of perception of job risk and lack of control. The subjective perception of job risk was a risk factor for both exhaustion and disengagement and lack of control over infection was a risk factor for exhaustion. Previous studies have emphasized the importance of a sense of control and security in psychological health and Glass and McKnight revealed a modest association between perceived uncontrollability and burnout [22,23]. It is possible that one’s perception of job risk and feelings of lack of control could result in feelings of helplessness, which in turn would result in HCWs detaching themselves from work and feeling exhausted. Preparedness can increase confidence in the ability to do a job as well as psychological well-being [24]. However, our results indicate that receiving MERS education was not protective against burnout, which is inconsistent with previous findings showing that perceived adequacy of training is a significant predictive factor [12]. Taken together, these findings suggest that MERS education programs should be revised to strengthen safety and have tougher anti-infection measures to better protect against burnout in HCWs.

In terms of experiences at the time of infection, we found that exposure to media was one of the most important factors. When exposed to media, individuals may feel like they are under constant surveillance and could be subjected to negative comments by anonymous people, which may lead to the experience of stress and withdrawal from work. For example, when MERS broke out in Korea, it was common to observe a social stigma against patients who recovered from the infection, the families of infected people, and HCWs. In this type of environment, exposure to media might be stressful and leave HCWs feeling alienated. Volpone and Avery [25] reported that perceived discrimination based on race, sex, age, family obligation, and/or sexual orientation is related to psychological withdrawal that leads to physical issues such as lateness, absenteeism, and the intent to quit. Our findings suggest that discrimination in society as well as in the workplace could lead to burnout among HCWs. Thus, social campaigns and practical measures aimed at decreasing excessive public fear and rumors toward HCWs may be helpful. On the other hand, we found that experience of MERS-like symptoms, quarantine, and exposure without the use of PPE were not significantly associated with burnout. It is possible that the number of HCWs who experienced these situations was insufficient to produce significant results.

We also found that prior work experience with infections was related to high levels of exhaustion, which indicates that experienced workers were more likely to feel tired. It is possible that prior work experience with treating infected patients could be traumatic for workers. For example, workers with repeated indirect traumatic experiences are more likely to experience burnout, and thus the identification and treatment of individuals with traumatic work experience may be effective for reducing future burnout in HCWs [26]. It is also possible that experienced workers might be overloaded and have significant responsibilities. A high work load is related to dissatisfaction at work and differences in quality of care, and thus it may be helpful to properly distribute work responsibilities and focus on experienced workers when intervening to prevent burnout in HCWs [27,28].

The present study had several limitations that should be considered. First, we included HCWs from only two hospitals, which may limit the generalizability of the results. Second, although we targeted individuals who performed certain tasks related to MERS, we did not assess the exact tasks that they did at that time, and thus it was not possible to determine which specific tasks or experiences were more likely to lead to burnout. Regardless, our findings suggest that HCWs in risky work situations were more vulnerable to burnout. Third, perceptions about MERS and exposure to MERS were not measured using validated scales. Although the subjective perception of infections is a very important factor related to psychological problems, an appropriate scale has yet to be developed. Thus, it will be necessary to develop and validate instruments that can measure subjective attitudes and perceptions about infections. Fourth, the numbers of HCWs who experienced MERS-like symptoms, were quarantined, and who were exposed to MERS without PPE were insufficient to produce significant results. Future studies should include a sufficient number of individuals with these experiences.

The present findings are meaningful in several ways. First, we found that a majority of HCWs in hospitals that treated MERS patients during the outbreak experienced burnout. Second, nurses, women, and experienced workers are more vulnerable to burnout. Third, our findings expand on previous findings by showing that personal strength and perceptions about infections are important factors that predict burnout in HCWs, which emphasizes the importance of personal strength factors, such as purpose and hope, in protecting workers against burnout. On the other hand, perception of high job risk and a sense of a lack of control are risk factors of burnout. Finally, our findings suggest practical ways to reduce burnout. For example, exposure to media is an important factor in burnout, which suggests that guidelines for the media coverage of epidemic diseases should be set.