Burnout syndrome among medical professions during the COVID-19 pandemic

Introduction

Burnout syndrome is an increasing threat to health care systems around the globe. After acknowledging the matter, the World Health Organization included burnout syndrome in the ICD-11 under the codename QD 85, defining it as “a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed”. As such, it is characterised by 3 dimensions: the feeling of exhaustion, cynicism related to one’s work, and the feeling of being undervalued in one’s line of work (combined with a sense of ineffectiveness) [1]. It has been estimated that the annual cost of burnout among healthcare workers reaches $4.6 billion in the United States alone [2]. Reports show that COVID-19, associated with higher rates of patient mortality, puts great strains on the mental health of healthcare workers, especially those who are already struggling with being underpaid, overworked and often unappreciated [3, 4].
The aim of this study was to assess the scale of burnout syndrome in a group of Polish healthcare employees and its effect during the COVID-19 pandemic. Additional aims included relation of age and experience to burnout and the assessment of potential prevention strategies reported by the questioned subjects.

Material and methods

During the period of March to September 2023, a total of 185 patients were enrolled in the study via an online questionnaire. Most of the recruited study subjects were nurses (113 people; 61% of the study group), followed by physiotherapists (63; 34%), physicians (6; 3%) and paramedics (3; 1.6%). The majority of the group were female (85%). After implementing inclusion/exclusion criteria, the authors removed 16 records from the analysis. Inclusion criteria consisted of a minimum 1 year working experience (in a dedicated medical field) and still being actively involved in a medical profession (at the time when the questionnaire took place). Exclusion criteria involved substantial gaps in the questionnaire, inconsistencies within the data, and reported workload of > 100 h/week. A detailed description regarding the study group is presented in Table 1. Due to the major disproportions in numbers between medical professions, the main analysis was focused on 2 medical groups in particular: nurses and physiotherapists.
The study was based on an online questionnaire using a commonly accepted tool – MBI HSS MP (Maslach Burnout Inventory, Human Services Survey for Medical Personnel) with an additional set of questions covering the basic information about the study subjects. The first part of the questionnaire (10 questions) covered topics such as the type of medical profession, specialty, place of work (public, private of both sectors), individual characteristics (age, sex), medical experience (years and hours per week) and lastly whether the person had been working on a COVID-19 dedicated ward (in the period 2021–2023). The second part of the questionnaire (MBI-HSS-MP) was divided into 3 sections including questions on: emotional exhaustion (EE, 9 questions), depersonalization (DP, 5), and personal accomplishments (PA, 8). All questions are scaled from 1 to 6 points, where a higher number on points in the EE and DP sections suggests increased risk of burnout, while for PA a lower number suggests that a patient is at risk. A detailed description of various levels of burnout risk depending on the number of points accumulated in the questionnaire is presented in Table 2 [5].
The last section of the questionnaire covered a list of potential stress-reducing strategies with a possibility to include additional ones proposed by the questioned medical professionals.
The study was approved by the Jagiellonian University Bioethics Committee (opinion no. 1072.6120.68.2022 from 21^st April, 2022).
In order to establish the distribution of data for particular variables, the Shapiro-Wilk test was used. In order to assess differences between groups, the authors used either the Mann-Whitney U test or the Kruskal-Wallis test. Values of p < 0.05 were considered to be statistically significant. Statistical analysis was performed with using SPSS software and the RStudio program.

Results

The results clearly demonstrated that the studied medical professionals are generally at high risk of burnout syndrome. With a total of 169 study subjects (mean age 37.2 years, 22–62, SD = 10.7), high risk of burnout was reported for the majority of the group in all 3 dimensions. High risk was reported for 45% of respondents in terms of EE, 59% for DP and 96% for PA (the values for medium risk were 29% EE, 28% DP and 4% PA). When the place of work was taken into consideration (COVID-19 ward vs other places), it became clear that the pandemic is not responsible for the high burnout scores. A total of 69 participants (41%) reported working on COVID-19 dedicated wards during the pandemic. The changes observed within the MBI HSS MP were not statistically significant. However, it does appear that the place of employment is of the essence, as those respondents working in the public sector were at lower risk of burnout (than those from the private sector or both) in terms of personal accomplishment (Table 3).
Neither the specialization nor working experience was statistically associated with the risk of burnout syndrome. Although the number of hours/week spent in the workplace and burnout were correlated in 2 dimensions (DP and PA), the dependence was weak and therefore not clinically relevant (DP – R = 0.18, p = 0.017; PA – R = 0.17, p = 0.032).
After conducting analysis on the basis of sex of the respondents, the study showed that it was not significant in terms of EE and DP, but there was a noticeable difference for PA. According to our study results, women were at a significantly higher risk of feeling underappreciated in their field of work. The median value for men in PA was 25 (IQR 6) vs. 20 (IQR 10.3) points in women (p = 0.005).
The major characteristics analysed in the following study, based on two medical professions (most commonly reported), are presented in Table 4.
The groups were comparable when most variables were considered, except one: the group of nurses was characterised by a significantly greater workload. This might be associated with the specifics of the professions, as nurses often work in long shifts, whereas physiotherapists often work in unscheduled hours with longer breaks in between hours. Regardless of that, none of the analysed dimensions proved to be differentiated by the reported profession. Physiotherapists had slightly worse results in EE and DP and better in PA, but these differences were not statistically significant (Table 5).
In order to assess potential strategies of dealing with stress and depression in the workplace, all respondents were asked about their personal experience on the matter. Next, the strategies were assessed in reference to the 3 burnout syndrome dimensions using the Mann Whitney U-test to evaluate how higher risk is associated with particular strategies. Some of the strategies were significantly more likely to be reported (Table 6).
Our analysis revealed that strategies such as hobbies (unrelated to work), pharmacotherapy and alcohol consumption are more likely to be reported by individuals with higher risk for EE. For DP these included avoiding work-related talk with family members, special courses and alcohol consumption. Lastly, those with lower scores in PA (higher risk) pinpointed working at different facilities and alcohol consumption. It should be emphasized that alcohol consumption is reported in all three dimensions.

Discussion

Available data show that the risk of burnout rises quite early within the medical professions, ranging from 27 to 50% during medical studies [6–8]. After a rapid start, the problem increases in the following years, especially when the person’s first medical post is considered demanding (e.g. oncology) [9]. In our study, we found that burnout syndrome was quite high in all 3 dimensions, as identified by Maslach (EE, DP, PA). PA was according to our results of greatest risk, with 96% of study subjects feeling highly underappreciated in their field of work. The risk of burnout was significantly higher in this case then in other reported studies in medical professions. According to Shah et al., 1 in 10 nurses resigned from their post in 2018 in the US – over 30% of those employees left because of burnout [10]. It is a matter of great importance considering the shortage in nursing staff across healthcare systems in most countries and an increased demand associated with potential pandemics like COVID-19. When it comes to physiotherapists, most studies report them being at low or medium risk for burnout [11, 12]. In our study, we did not identify major differences between nurses and physiotherapists in terms of burnout; however, the group of nurses had a significantly higher weekly workload – which might put them at higher risk, as reported by Diehl et al. [13]. According to Venturini et al., physiotherapists worldwide are generally at high risk of burnout, especially in developing countries [14]. The background of the workplace is of importance as well – whether the person works in the public sector, private sector, or both at the same time. In our study, the results suggest that those working in the private sector or in both are more likely to feel appreciated for their job (p = 0.039). Our results are in line with the study by Dinibutun – who had a similar observation, in favour of the private sector, and also noted that the difference was significant for other burnout dimensions as well [15]. The observation is of high importance, as it shows that in many cases the burnout risk might have been reduced if proper preventive measures had been taken by the medical professionals in a timely manner. These might include proper incentives, employee assistance programs, leadership training, professional development opportunities, reasonable duty allocations as well as occasional screening for early burnout signs [16–18].
At the same time, most of the medical professionals are searching for stress-relief techniques by themselves. Our study shows a disturbing trend across every burnout dimension when it comes to prevention strategies. Increased burnout risk for EE, DP and PA was associated with alcohol consumption reported by the study subjects. Other strategies were also likely to be reported, such as job-unrelated hobbies (for EE), avoiding work-related talk with relatives (for DP), pharmacotherapy (EE) and attending stress-relief courses (DP). Similar results regarding alcohol consumption have been reported by Efa et al. [19]. Among 360 nurses who participated in the study, over 49% were identified as high burnout risk cases, with alcohol drinking as a significant risk factor (with an adjusted OR of 3.81). Tao et al. reported alcohol misuse among clinical therapists to be relatively low at 6.6% of the study group but also noted a strong association with depersonalization (OR = 4.85). According to the authors, alcohol misuse is more common among men than women (OR = 3.37) [20]. As reported by Jackson et al., it appears that the problem starts at an early stage of the medical education. In their US study on a group of 4,402 medical students, EE and DP dimensions were both at high burnout risk for those who were abusing/dependent on alcohol [21].
Most studies report that women are more likely to develop burnout syndrome in a medical profession and to question their career choice [22, 23], whereas in our study we found a difference only in the dimension of personal accomplishments (PA). Women were more likely to feel undervalued when compared to men (p = 0.005). It is possible that our results are partially biased due to the underrepresentation of men in the study group (25 vs. 144 women). As reported by Malinzak et al. in their study on female anaesthesiologists, greater risk for this group may be associated with greater harassment risk, compensation inequity, decreased rates of promotion, less representation in leadership, and inequitable distribution of domestic duties [24]. This list may be supplemented by educational debt, as described by Verduzco-Gutierrez et al., who found that over 90% of physiotherapists faced financial challenges [25].
Despite the variety of studies in multiple medical professions, all authors are in agreement about one thing. The problem of burnout in those with a medical background is significant, and there is a lack of proper prophylactic measures at most medical facilities. Being underpaid, undervalued, and working long shifts in high stress situation put this working group at great risk. According to the recent report on the status of nurses in Poland, prepared by the Polish National Chamber of Nurses and Midwifes, the average age of nurses in Poland is 54 years [26]. This is significantly higher than the nearby Slovakia (46.9 years), Czech Republic (46.1) or UK (43.8) [27].
While as authors we made every effort in the research, certain limitations could not be avoided. First of all, the study is an anonymous questionnaire and the authors had no possibility of verifying the facts reported by the participants. At the same time, most studies on burnout are organized in a similar manner. Secondly, the authors had no impact on the type of medical profession included in the study. As a result, the numbers of people in particular medical professions are not even (specially for physicians and emergency medical technicians) – hence the decision of the authors to focus the study on the 2 most commonly reported professions: nurses and physiotherapists.

Conclusions

Burnout syndrome was a major problem for medical professionals in our study group but was not significantly affected by COVID-19. Nurses and physiotherapists were equally at risk. There is a great need for proper prophylactic guidelines to minimize the use of alcohol and drugs as preventive measures among medical employees.

Disclosures

1. Institutional review board statement: The study was approved by the Jagiellonian University Bioethics Committee (opinion no. 1072.6120.68.2022 from 21st April, 2022).
2. Assistance with the article: None.
3. Financial support and sponsorship: None.
4. Conflicts of interest: None.

References