|Year : 2021 | Volume
| Issue : 1 | Page : 50-56
A comparative study to assess burnout and its correlates among doctors and nurses working at dedicated COVID-19 facility of civil hospital, Ahmedabad, Gujarat
Minakshi N Parikh, Dhruvkumar Shaileshbhai Patel, Vrunda Ashok Patel, Parth R Kansagra
Department of Psychiatry, B. J. Medical College and Civil Hospital, Ahmedabad, Gujarat, India
|Date of Submission||28-Dec-2020|
|Date of Decision||23-Jan-2021|
|Date of Acceptance||23-Jan-2021|
|Date of Web Publication||18-Jun-2021|
Dr. Dhruvkumar Shaileshbhai Patel
9/Raw House, Riddhi Siddhi Park, R. C. Technical Road, Near Sayona City, Chandlodia, Ahmedabad - 382 481, Gujarat
Source of Support: None, Conflict of Interest: None
Background: The high contagiousness of the COVID 19 disease, the uncertain course, and the high morbidity and mortality has led to unprecedented burden on the health care system, especially when the crisis has gone on for more than 5 months with no end in sight. The chronic high degree stress has made burnout in health care workers (HCWs) a reality that needs urgent attention which can otherwise lead to compromised patient care apart from their own suffering. Aims and Objectives: This study was planned to assess and compare the burnout in doctors and nurses of our dedicated COVID 19 hospital, to understand its correlates, and look for any implications on future policy decisions. Materials and Methods: Our study assessed and compared the burnout in 150 doctors and 150 nurses of our dedicated COVID 19 hospital using the Copenhagen Burnout Inventory (CBI). The CBI Scale is a 19 item scale including three domains of burnout in the form of personal (1–6), work related (7–13), and patient related burnout (14–19). More than 25% average score on these items is taken as the presence of burnout. Results: We found burnout in 58% of all HCWs with 78% in doctors (n = 150) and 38% in nurses (n = 150), the difference being statistically significant. Multiple linear regression analysis was performed to find common factors affecting burnout among both the groups, which were female gender, facing stigma due to COVID 19 duty, regular exercise/yoga, and dissatisfaction with administrative services. Our findings propose to emphasize the need to address the impact of working under pressure for sustained periods among HCWs.
Keywords: Burnout, COVID-19, doctors, nurses
|How to cite this article:|
Parikh MN, Patel DS, Patel VA, Kansagra PR. A comparative study to assess burnout and its correlates among doctors and nurses working at dedicated COVID-19 facility of civil hospital, Ahmedabad, Gujarat. Ann Indian Psychiatry 2021;5:50-6
|How to cite this URL:|
Parikh MN, Patel DS, Patel VA, Kansagra PR. A comparative study to assess burnout and its correlates among doctors and nurses working at dedicated COVID-19 facility of civil hospital, Ahmedabad, Gujarat. Ann Indian Psychiatry [serial online] 2021 [cited 2021 Aug 5];5:50-6. Available from: https://www.anip.co.in/text.asp?2021/5/1/57/318678
| Introduction|| |
On March 19, 2020, the first case of novel coronavirus disease was diagnosed in Gujarat, which got admitted to 1200-bedded dedicated COVID-19 hospital of Civil Hospital, Ahmedabad (CHA). For initial days, it was the only dedicated COVID-19 facility in Ahmedabad. Hence, since the appearance of the first case, doctors and nurses of CHA are working shift by shift continuously and tirelessly. The high contagiousness of the disease, the uncertain course, and the high morbidity and mortality of COVID-19 illness leads to unprecedented burden on the health-care system. Long and intense working hours, wearing a personal protective equipment (PPE) kit, facing grief with no end in sight, chronic fear of getting infected while treating patients and transmitting it to close ones can all lead to physical and emotional exhaustion in health care workers (HCWs) which might result in burnout.
Burnout is a psychological syndrome first described by Maslach et al. and defined as a state of psychological, emotional, and physical stress in response to prolonged exposure to occupational stress. The World Health Organization defines burnout as “;a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed, characterized by feelings of exhaustion, increased mental distance from one's job and reduced professional efficacy.” Burnout is described in five different stages. The first stage is termed as “honeymoon phase” which includes job satisfaction, sustained energy levels, commitment to the job, and compulsion to prove oneself which results in high productivity. The second phase is “onset of stress” which includes inability to focus, irritability, anxiety, and job dissatisfaction leading to lower productivity. If continued, it may progress to the third phase known as “chronic stress” including lack of interest, persistent tiredness, missed work deadline, and feeling pressured and in some individuals increase in the use of caffeine and nicotine. Chronic stress can finally progress to burnout with symptoms such as feeling empty, self-doubt, behavioral changes, headache, and desire to move away from work. The fifth and final phase of burnout is known as “habitual burnout” which comprises chronic mental and physical fatigue, sadness, and depression collectively called “burnout syndrome.”,
Not only do the victims of burnout suffer but also their involvement in work decreases and errors increase and this can lead to a poor quality of patient care which can sometimes lead to far-reaching consequences.
After nearly 5 months of continuous duty, and COVID-19 disease keeping up its scores against all our prayers and hope, the spirit of HCWs was destined to go down. No Indian study till date has compared burnout among doctors and nurses in this COVID-19 pandemic situation.
Aims and objectives
This study was planned to assess and compare the burnout in doctors and nurses of our dedicated COVID-19 hospital, to understand its correlates, and look for any implications on future policy decisions.
| Subjects and Methods|| |
Study design and population
This is a cross sectional study to assess burnout among doctors and nurses who have done at least 30 days of COVID 19 shift duties in total with at least one rotation in the last month; wearing PPE kit, at a dedicated government COVID 19 facility having 1200 beds in Ahmedabad. We enrolled 150 resident doctors and 150 nurses in our study for which we had to approach 390 HCWs through purposive sampling. Ninety of them could not be enrolled either because of a lack of willingness or due to incomplete forms.
Data were collected using online Google Forms which included basic demographic information and work-related details such as work experience, days of COVID-19 duty, qualification, designation, and the self-rated 19-item Copenhagen Burnout Inventory (CBI) to measure burnout prevalence.
All the study participants were asked a list of various personal factors such as feeling happy to have made a difference, increased endurance levels, and having learned a lesson while obtaining sociodemographic data. Although these questions are not part of any validated scale, they were included in the study considering their role in causing burnout.
CBI is a 19-item scale including three domains of burnout in the form of personal (1–6), work-related (7–13), and patient-related burnout (14–19). It is a Likert scale that can be rated from 0 (never), 25 (seldom), 50 (sometimes), 75 (often) to 100 (always). The mean score of 19 items as well as each domain can be considered for measurement of burnout. The mean total CBI score of 25–49 indicates low burnout, while 50 or more indicates moderate to high burnout.
SPSS version 20.0 (IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp.) was used to analyze the data. Pearson's Chi-square test, Student's t-test (paired and unpaired), and multiple linear regression analysis were used to assess the correlation between different variables and mean CBI scores. P < 0.05 was considered statistically significant. Distribution of various demographic variables between both groups is shown in the [Table 1].
|Table 1: Distribution of demographic variables among both the study group|
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| Results and Discussion|| |
The mean age for doctors was 26 as compared to the mean age of 32 in nurses. The mean years of experience for doctors was 2.62 as compared to 9.48 for nurses. Most (95.33%) of the nursing staff were married, and in doctors, 83.33% were unmarried and 16.67% were married. The distribution of males and females was almost the same in the doctors' group, while in the nurses' group, most were females, as in our country, nursing profession is predominantly chosen by females. All the participating doctors were resident doctors, so it justifies the difference of marital status and mean work experience among both the groups.
Eighty-four percent of doctors and 83.33% of nurses had at least one intensive care unit (ICU) posting during their COVID-19 duty [Table 2]. 27.33% of doctors did COVID-19 duty for more than 45 days in total, while almost all (99.33%) nurses had total days of COVID-19 duty <45 days. Thirty-four percent of doctors belonged to medicine, 46% from anesthesia and Tuberculosis and Chest Department (TBCD), and 20% to other specialties, respectively. Ninety-four percent of doctors and 79.33% of nurses were away from their family for at least 1 month during their COVID-19 duty. Sixty percent of doctors and 28.67% of nurses were not satisfied with the administrative services.
|Table 2: Distribution of various clinical variables among both study groups|
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41.33% of doctors and 33.33% of nurses faced stigma due to their COVID-19 duty. 25.33% of doctors got COVID positive as compared to 6.67% of nurses. Family member of 9.33% of doctors and 26% of nurses got COVID positive during their duties. Nine doctors and 6 nurses reported death in their family due to COVID-19 infection.
Excessive burden on the unprepared health-care system caused by novel coronavirus forced the HCWs to go beyond their limits and find novel ways to deal with the situation. Considering this, a list of various personal factors was prepared and the questions were asked while obtaining sociodemographic data as shown in [Table 3]. Although these questions are not part of any validated scale, they were included in the study considering their role in causing burnout. 83.33% of doctors and 54% of nurses felt that they have made a positive difference at their workplace. Majority of the doctors (92.67%) and nurses (94.67%) were happy to have made their contribution toward this pandemic. Seventy-eight percent of doctors reported that their endurance level is increased as compared to 82% of nurses. Ninety-four percent of doctors and 90.67% of nurses reported that they have learned their lessons from this pandemic. Eight percent of doctors and 4.67% of nurses had a history of psychiatric illness. 25.33% of doctors were doing regular exercise/yoga as compared to 32.67% of nurses.
|Table 3: Distribution of various personal factors that can lead to burnout among both the study groups|
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According to CBI, the mean burnout score of 25 or more is suggestive of burnout and score of 50 or more suggests high burnout. In our study, 58% of staff among the whole study population (n = 300) were having burnout. 78% of doctors (n = 150) and 38% of nurses (n = 150) were having burnout, the difference being statistically significant [Table 4].
High burnout (CBI score ≥50) prevalence rates were 25% in the whole study group, 25.33% among doctors, and 24.67% among nurses without any significant difference among both the groups. The prevalence rates of low burnout (CBI score: 25–49) were 32.67% among the whole study group (n = 300), 52.67% in doctors, and 12.67% in nurses, respectively, the difference being statistically significant [Table 5], [Table 6], [Table 7]. A study measuring job stress and burnout among different medical professionals found the highest prevalence of burnout among nurses as compared to others (physician assistant, physicians, and medical technician). Another comparative study measuring burnout across various emergency medical professionals found physicians having significantly high scores than nurses (71% and 66%, respectively) for emotional exhaustion component of the Maslach Burnout Inventory. The differences in result could be due to different work settings as well as different circumstances in the form of the current study being done during COVID-19 pandemic.
|Table 5: Various clinical variables and prevalence of burnout among the doctors' group (Chi-square test)|
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|Table 6: Various clinical variables and prevalence of burnout among nurses (Chi-square test)|
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|Table 7: Comparison of mean Copenhagen Burnout Inventory score according to domains of burnout among both the study groups|
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As compared to nursing staff, doctors have high responsibility and more pressure of work, have quick decision-making, have to face the grief of distraught relatives, and have to report back to higher authorities. These can be the reasons why doctors are having high prevalence of burnout. Various clinical variables and prevalence of burnout among doctors group in shown in [Table 5].
Age, marital status, and years of experience could all contribute to low burnout rates in nurses as majority of the nurses were married and had more years of experience in their field as compared to resident doctors.
Among the doctors' group, clinical variables such as ICU posting, days of duty, and specialty were the assumed factors that may lead to high burnout among them. In our study, 87.81% of doctors out of 41 doctors who did COVID-19 duty for more than 45 days were having burnout compared to 72.47% (n = 109) doctors who did COVID-19 duty for <45 days (P < 0.05). 78.57% of doctors out of 126 who got ICU posting were having burnout compared to 66.66% out of 24 who did not have ICU posting, though the difference not being statistically significant. High burnout in ICU posted doctors is justifiable, as in ICU, there are critical patients who require intense management, high viral load in patients, and more contact with patients. Burnout prevalence rates among doctors belonging to general medicine, emergency medicine, and pediatric specialty were 88.24% out of 51. Among anesthesia, respiratory medicine, and ENT specialty, burnout prevalence rates were 72.46% out of 69. In other specialties, rates were 66.66% out of 30 doctors.
In our study, 149 nurses did COVID duty for 30–45 days, while only one nurse was posted for COVID duty for >45 days. Out of 149 nurses who did COVID duty for 30–45 days, 57 (38.26%) reported burnout, while the one nurse posted for >45 days did not report any burnout. The difference between the groups was not statistically significant.
Out of 150 nurses, 143 did ICU posting while the other 7 did not do ICU COVID duty. Out of the 143 who did ICU duty, 55 (38.46%) reported CBI score ≥25. Out of 7 who did not do ICU posting, 2 (28.57%) reported burnout. The difference was not statistically significant.
As mentioned in [Table 6], the mean CBI score for the whole study population was 32.00; in doctors, it was 37.23 and in nurses 26.77. The mean difference between the two groups was significant with P < 0.05, the doctors' group having significantly higher mean burnout score than the nurses' group. The mean CBI scores for personal burnout were 44.28 and 34.92, for work-related burnout 39.07 and 27.79, and for patient-related burnout 28.06 and 20.94 in doctors and nurses, respectively. Hence, the mean CBI scores for all three domains were significantly higher in doctors than nurses (P < 0.05). The mean CBI score for patient-related domain (25.44) was significantly lower than the mean total CBI score across both the groups (32.00), which indicates that working with patients does not add up to the burnout faced by health-care professionals as they are well trained and experienced to work with patients. A cross-sectional survey in different clinical professionals also found significantly lower burnout mean scores in patient-related domain using the same instrument as our study.
CBI includes questions related to personal burnout such as “how often do you feel tired?” and “how often do you think I cannot take it anymore?” and questions linked to patient-related burnout such as “are you tired of working with patients?” and “do you sometimes wonder how long you will be able to continue working with patients?” As mentioned in [Table 8], both doctors and nurses had significantly high personal burnout mean scores (44.25, 34.92) as compared to patient-related burnout scores (28.14, 20.94). This infers that doctors and nurses are not hesitant or afraid of working with patients as they are confident about patient management and well trained for that whereas personal burnout is reflection of their own exhaustion and uncertainties in the face of complete disruption of work routine, studies, academic work, and examinations. Hence, patient-related burnout scores are significantly lower than the personal burnout scores in both the groups.
|Table 8: Comparison of personal burnout and patient-related burnout mean scores among both the study groups (one-sample t-test)|
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Multiple linear regression analysis was performed to find common factors affecting burnout among the doctors' group, which were facing stigma due to COVID-19 duty, regular exercise/yoga, happy to have made a contribution toward pandemic, and satisfaction with the administrative services [Table 9].
|Table 9: Multiple linear regression analysis between various factors and mean total score of burnout among the doctors' group|
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Facing stigma due to COVID-19 duty was associated with high burnout among the doctors' group with a beta value of 0.22, while getting COVID-19 positive during duty was not a significant factor affecting burnout. This suggests that medical and paramedical staff are aware of their professional risks which includes getting infected while on duty however not getting validation from society and facing stigma instead predisposes them to burnout. A recent study by Ramaci et al. suggests that social stigma of COVID-19 is an important predictor of burnout and fatigue among health-care professionals.
Doctors who were doing regular exercise, yoga, or meditation had significantly lower mean scores of burnout.
In the face of chronic stress, regular exercise and yoga are helpful stress management strategies. Previous researches also suggest that regular exercise and yoga increase resilience leading to lower burnout levels. Hence, as a protocol, all our HCWs underwent an induction training before their COVID 19 duty. As a part of this training psychiatry department took a session on stress management and taught simple exercises and yoga and encouraged them to do it regularly. Corroborated by researches that regular exercise and yoga increase resilience and mindfulness that is correlated with lower burnout. A systematic review by Rosario Andrea Cocchiara et al. concluded that yoga and meditation significantly reduce stress and burnout.
Satisfaction with the administration and feeling happy to have made a contribution toward pandemic was associated with low burnout score in doctors.
Gender, marital status, being away from family, getting COVID positive while on duty, and feeling to have made a positive difference at workplace were not found to be statistically significant in our study.
Multiple linear regression analysis was performed to find common factors affecting burnout among the nurses' group, which were female gender, facing stigma due to COVID-19 duty, and regular exercise/yoga [Table 10].
|Table 10: Multiple linear regression analysis between various factors and mean total score of burnout among nurses|
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According to data, females are at high risk for developing depression as compared to males; this may explain high rates of burnout among females. Many studies measuring burnout reported women having higher burnout scores, particularly personal burnout domain across all the groups. Facing stigma due to COVID-19 duty was the most significant factor among the nurses' group with a beta value of 0.46.
Nurses who were doing regular exercise, yoga, or meditation had significantly lower mean scores of burnout.
Marital status, being away from family, satisfaction with the administrative services, getting COVID positive while on duty, feeling happy to have made a contribution toward the pandemic, and having made a positive difference at workplace were not found to be significant in our study.
| Conclusion|| |
HCWs' duty hours need to be moderated, especially in resident doctors. Proper training about work and implementation of stress management techniques should be done before COVID-19 duty with more focus toward administrative services to reduce the prevalence of burnout.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10]