Abstract

Background: Burnout is a rising concern amongst healthcare professionals and has been studied and classified as a psychological disorder, resulting from physical and emotional overload involved in the training periods. Objective: This study aims to identify the burnout among trainees, based on individual trainee response, and examine the possible existing relationships between the magnitudes of burnout syndrome and selected variables. Subjects and Methods: It is a Cross-Sectional design undertaken in a training center at specialized hospital, Makkah, Saudi Arabia. Valid sample collected from 420 trainees using Maslach Burnout Inventory (MBI), which was designed with the goal of assessing an individual's experience of burnout survey. Results: shows that the personal achievement was impacted the mostly, which shows that the participants have less personal achievement, that is, less competence and successful achievement in one's work with people. Depersonalization comes as second affected dimension of burnout that means unfeeling and impersonal response toward recipients of one's service & care. Lastly, emotional exhaustion was the third dimension in prevalence among the trainees. Finally, the Pearson correlation test result shows that moderate positive significant link between the emotional exhaustion, depersonalization with Burnout among trainees. In addition, result showed a significant relationship between the dimensions of burnout and training level. In regards to smoking status and training level showed a significant relationship with the severity of burnout. Conclusion and Recommendations: healthcare organizations should focus on the need of assessing trainees’ burnout, as that will provide basic understanding of the perceptions of their burnout level during training periods. Personal and institutional based reforms focused on improving the work environment of residents & trainees, may lead to a significant reduction in the levels of burnout. More studies are needed to understand the coping mechanisms to prevent and reduce the effects of burnout among trainees.

1. Introduction

Healthcare training and certification is one amongst the foremost important milestones of the healthcare practitioners’ life which can change the longer-term path of them. During this era the practitioner build their theoretical likewise practical aspects of their specialties and reshape their own personality and self-confidence to beat the professional challenges ¹. So as to realize that it's expected to face some psychological challenges which may negatively impact his/her educational and vocation. Those challenges may be within the type of alertness, depression, or burnout ².

Psychological workplace burnout - in one amongst its definitions - is described as a situation of psycho-mento-physical exhaustion, that's expressed by the trainee-practitioner against their work. Another definition by Dimitriu et al., that burnout is described as “variety of negative consequences including depression, risk of medical errors, and negative effects on patient safety” ¹.

Burnout Syndrome (BOS) is synonymously known as “Occupational Burnout”, “Exhaustion Syndrome”, “Burnout”. Burnout was first flagged in 1974 by Herbert J. Freudenberger as prolonged response to chronic emotional and interpersonal stressors on the work among healthcare volunteers ³. He described that burnout mainly involves three areas, first is emotional exhaustion which is feeling depleted of emotional resources, second is depersonalization that is negative cynical detached response to people, and at last the thirds is reduced personal accomplishment and feelings of inefficacy at work ². Maslach burnout model for medical professions emphasized on when there's gap or imbalance between demands and resources the result's exhaustion ⁴.

For residents’ burnout Alhaffar et al., 2019 pointed in their study to four main causes: 1) lack of control over work conditions and decision making; 2) physician perception that they were only valued for his or her productivity additionally to time pressure; 3) work environment that physicians practice clerical and other mundane tasks are chaotic and inefficient; and 4) malalignment among physicians and executives regarding mission, vision, values, and compensation ⁵.

Burnout among physicians is estimated to range between 19% and 76% ⁶. Stratification by country estimated 22% within the USA, 27% in Britain, 20% in Germany, 32% in Italy. Burnout among residents during COVID19 continues to be under-studied. Resident physicians are the link between the MRP (Most Responsible Person) and the patient, they need the foremost prolonged contact with patients, including “waiting for result” time, and therefore the strain is even more pronounced on them ². Moreover, excessive heat because of continuous usage of personal protective equipment, and decreased hydration ⁷.

In addition to what was mentioned in previous paragraph, there are more factors that raised burnout during COVID19 era including – but not limited to – decreased quality of care caused by huge increase in demands; extra-long duty hours; frequent work shifts; sleep deprivation; handling suffering and dying patients; fear of creating mistakes; lack of autonomy; new expectations; competitiveness; and inadequate support from supervisors. Dyrbye and Shanafelt, 2016 Added other risk factors for burnout among residents as individual mood, added family stress, single, conflict with clinical faculty and the first year of residency ⁸.

2. Significance of the Research

Burnout is a rising concern amongst healthcare professionals and has been studied and classified as a psychological disorder, resulting from physical and emotional overload involved in patient care. Trainees suffering from burnout syndrome have a low personal implementation on their job description, depersonalization, cynical or negative attitudes towards patients, and emotional exhaustion.

As a build-up on existing literature, this research proposal aims to investigate the burnout among trainees in King Abdullah Medical City (KAMC) training center at Makkah, based on individual trainees. Notwithstanding the gravity of the situation with the burnout syndrome amongst trainees worldwide in general and particularly in the Saudi context, it is evident that there has been a lack of structural research in exploring the various elements which manifests itself eventually in the burnout syndrome. In addition to judge if the burnout is present among SCFHS trainees at King Abdullah Medical City –Makkah hospital, this study will also explore the proportion and severity of the burnout. Additionally, this research also aims to work out the foremost important contribution factors for the burnout. During the entire architecture of this study, the need to reform organizational habits and modifications in training center was evaluated as a viable solution to the problem at hand.

3. Aim of the Study

The aim of this study was to disclose the burnout among trainees in KAMC training center. This aim is achieved through the following objectives:

1. To assess the presence (severity & dimensions) of the burnout syndrome among SCFHS trainees in KAMC, Makkah

2. To find out the correlation between severity & the different dimensions of burnout among KAMC trainees.

3. To look for any existing links between the burnout syndrome (dimensions & severity) and selected variables among KAMC trainees

4. Subjects and Methods

This study was a cross-sectional research design that was carried out in training center at King Abdullah Medical City –Makkah. The population in this study includes 420 SCFHS trainees performing training at King Abdullah Medical City (KAMC). The inclusion criteria included getting training in different departments and units with those interested in participating in the study and those who have age of 23 or more, and fellow with age 27 or more. The exclusion criteria included those who have age of 23 or less, and fellow with age 27 or less.

The population total number was 560 in June 2021. This study was majorly focused on trainees in all the area response section who have a higher likelihood of experiencing burnout as compared to others affiliated to different departments and units. The minimum sample size by total number of resident trainees is 227 using the sample size calculator at 95% confidence interval and 5% margins of error. Total number of valid samples is 420 (after exclusion of invalid inputs) in this study assuming a minimum response rate of > 50%.

Data collection was done by using survey which included two parts. The first part of the survey was containing sociodemographic data (gender, age, academic sponsor center, training level, smoking habits, and specialty of training program, was the training before or after COVID19). On the other hand, the second part of the survey will consist of the Maslach Burnout Inventory. The original form of the MBI was developed by Christina Maslach and Susan E. Jackson with the goal of assessing an individual's experience of burnout ⁹. The MBI contain total of 22 questions which are grouped into three categories, The MBI contain 22 questions, which are grouped into three categories, nine questions evaluate emotional exhaustion, and five others investigate depersonalization, whereas eight remaining questions investigate personal accomplishment. Each scale measures its own unique dimension of burnout. The MBI is a Likert scale with 7 points and 22 items (“0” never, “1” few times annually, “2” once monthly, “3” few times per month, “4” once weekly, “5” few times per week, “6” - daily) that each trainees self-reports.

5. Validity and Reliability

In Kang and Kim's validation study (2012), examined the applicability of the Maslach Burnout Inventory on measuring burnout of the nurses who works in Korean university hospitals. The sample included 200 nurses and nurse managers. They used 22-item Maslach Burnout Inventory to evaluate the reported burnout. They evaluated the convergent validity through the factor analysis and evaluated the discriminant validity through the Pearson's correlation analysis. Also, evaluated the reliability for three subscales of Maslach Burnout Inventory with the Cronbach’s, which assesses the internal consistency. The results show that Maslach Burnout Inventory demonstrated high convergent validity. The Cronbach's coefficients in the 22-item Maslach Burnout Inventory and three subscales were higher than 0.7 that is Cronbach's α was 0.85 (overall scale), 0.91 (emotional exhaustion), 0.79 (depersonalization), and 0.84 (decreased personal accomplishment).

6. Ethical Considerations

IRB approval was obtained from the KAMC research Center letter 21-837, dated 28th September 2021. After getting official permission from IRB, the online survey was distributed to the SCFHS trainees. For ethical consideration, the aim of the study and an information part explaining the study details was included in survey to obtain their cooperation. Participants was not identified on questions. In this way the researcher was maintained anonymity and confidentiality of the participants.

7. Data Collection

The investigator collected data from the participants by using online survey questionnaires. The data was collected from 15/10/2021 to 15/11/2021. The survey link was opened to get the maximum number of respondence until no more responses were obtained for several consecutive days. An invitation part was included in the survey to understand the aim of the study to the participants and to obtain their cooperation. An information sheet was provided before starting to answer the questionnaires. The participants were made aware through the questionnaire that by proceeding to next online page & submission of online survey would indicate their consent to participate. The participants had the right to refuse taking part in the study without any penalty or negative feedback. The study samples were selected by using simple random method.

8. Statistical Analysis

The categorical variables were presented as frequency and percentage, while a Chi-tests was performed to compare the quantitative variables between different groups of trainees in KAMC. Pearson correlation was utilized to look at statistical relationship between burn out among SCFHS trainees and variables being studied. All statistical analyses were performed by using “Statistical Package for Social Sciences (SPSS)”, version 25 and P-values <0.05 were considered statistically significant.

9. Results

Table 1 illustrates that the mean score and deviation of the three dimensions are Emotional Exhaustion 21.37 (14.094), Depersonalization 10.45 (7.140) and Personal Accomplishment 26.14 (12.109). The result indicate that PA is the most positive dimension of the BOS with mean below the cutoff of 34, followed by DP with mean above the cutoff of 10, & the least affected one was EE with its mean is below the cutoff of 27.

The study results revealed that Age is high with PA (62.6%) and mild severity (29.3%). (Figure 1, Figure 2)

Regarding Smoking the study results showed that nonsmoker and smoker high with PA (26.7%, 36%) respectively, with smoker group has higher BOS that non-smoker. According to the severity of burnout they are mostly mild (13.3%, 16%) respectively. (Figure 3, Figure 4)

Regarding academic institution sponsor the study results showed that trainees from KAMC and outside scored mostly in the dimension of PA (33.1%, 29.5%), with KAMC residents were majority of them. For the rest of the dimensions non-KAMC residents represented the majority. Moderate severity of burnout was the dominant grade with score of (31%) in KAMC trainees and mild severity (15.7%) for non-KAMC trainee. (Figure 5, Figure 6)

The study results revealed that rotation in KAMC after COVID19 had the highest rates of BOS most of them at the dimension of PA (46.2%) and rotation in KAMC before COVID19 had the highest rates in PA (16.4%). The highest severity for after COVID19 were at the mild severity (20.2%). (Figure 7, Figure 8)

Moreover, All levels of training are high in PA. The degree “present” in the severity of burnout is high with Residents than fellow, and it was mainly at the dimension of PA (48.6% and 14%) respectively. The dominant severity level was “mild” for residents (22.1%) & “sever” for fellows (14.5%).(Figure 9, Figure 10)

Table 2 presents the Pearson correlation to determine the relation between independent variables with Burnout among trainees. The outcome reveals a medium positive correlation between Emotional exhaustion and Depersonalization, the p-value is computed at 0.000, which is less than 0.05, which means significant link between the emotional exhaustion, depersonalization with Burnout among trainees. Also, a significant P-value was revealed between the dimensions of burnout and training level (0.20)

Table 3 presents the association between the severity of burnout and characteristics (gender, smoking status, institution, last rotation at KAMC, and training level). In regards to smoking status showed a significant P value (0.018) non-severity. Also, a significant P-value was revealed between the severity of burnout and training level (0.006). Finally, as displayed in Table 4, significant correlations were found for all included variables.

10. Discussion

The result of this study indicated that PA is the most affected, which shows that the participants have less personal achievement perceived. DP is the second affected dimension, which shows low burn out, and EE is the least BOS dimension as per the participants’ perception. These results are consistent with the previous study results that burnout syndrome is mostly connected with the three most common domains, which are: emotional and physical exhaustion, cynicism and depersonalization ¹⁰. This result is in contrary to another study supporting the findings that among the individual subscales emotional exhaustion was most frequent in residents ⁷. Several studies found that residency status in itself contributes to burnout ¹¹ or burnout peaks earlier in residency training which subsides, at least on the Emotional Exhaustion dimension, as training progresses ^{12, 13}.

Many studies have shown medical residents from various specialties, internationally, experienced moderate burnout ¹⁴. An elevated level of emotional exhaustion, and/or a high score for depersonalization, and/or a low personal accomplishment score ¹⁵. Some of the studies suggest a high prevalence of burnout among trainees, with levels higher than in the general population ⁸. One of the nursing studies supporting this result that burnout syndrome in nursing, emotional exhaustion, and other recorded incidences are also causes and instigators of intention to leave among nurses around the world ¹⁶. Another study found that nurses had expended both physical and emotional energy in working as hard as they can in the hopes of receiving praise or recognition for their efforts ¹⁷.

One of the Syrian study result shows that most of the sample had a high level of (EE), had a high level of (DP), and a low level of (PA). Most of the residents included in the study had a high level of burnout in all three domains of the index, and a high level in at least one of the three ⁵. One study result supporting that emotional exhaustion has higher mean score which means the trainees have higher emotional exhaustion and similar results published in some nursing articles ¹⁸. According to a study done by the American Nurses Association, 50 percent of nurses were emotionally drained after concluding their shifts ¹⁹. Previous research has found that stress from the social and physical working environment, management, and job ambiguity are substantially associated with emotional exhaustion among medical practitioners ²⁰. Practitioners with burnout syndrome have a poor personal execution of their job description, depersonalization, cynical or negative attitudes toward patients, and emotional weariness ²¹, and they eventually feel exhausted and disoriented ²².

The current study also examined the relationship between the dimensions and severity of burnout with study variables. The result was females and males had higher levels of Personal accomplishment impact. The grade the severity of burnout is “present” for females and “mild” in males. While high stress and burnout results were more in males, with most affected dimension was personal achievement for both genders. This contrasts with literature stating that females trended higher on Emotional Exhaustion scores ²³ while males trended higher on Depersonalization ²⁴, Other studies showed men score higher persistent burnout ¹². One of the study findings was male physician’s registered higher levels of EE and DP and lower levels of PA than female physicians, with the knowledge that this difference was statistically significant only for emotional exhaustion dimension, although the opposite is usually reported by other studies ⁵.

In the next variables the relationship of burnout with the age of the study participants the result was age is having high relation with personal accomplishment and mild severity of burnout with the average age 29 years and these results also supported that in some cases, burnout was found to be associated with younger age groups ²⁴ but is higher among medical trainees than the general 22-32-year-old demographic ¹¹. When looking the relation of burnout with Smoking status the result was that nonsmoker and smoker high with PA and according to the severity of burnout, they are mild, these results are also consistent with Fernandes et al., 2018 it suggested that there was a positive association of the burnout syndrome with smoking in ICU professionals. Another study result shows that among residents Smokers tend to be more depressed than non-smokers ²⁵.

The other study variables were Trainees from both KAMC and outside high with personal accomplishment. The severity of burnout was Moderate severity in KAMC trainees and mild severity with a non-KAMC trainee. There is not much supporting study showing same result, but some study has influence in the training center that is Llera and Durante, 2014 reported a significant correlation between the educational ambience and burnout (an inverse correlation with EE and DP, and a direct correlation with PA) during the residency program ²⁶. Dyrbye et al. 2006 analyzed the learning environment and burnout in medical students, and found environmental factors associated with distress, establishing that the learning environment seems to be a critical factor for satisfaction. Another study result revealed regarding the training environment that residents working in the ministry of defense’s hospitals, had the highest rates of high EE and DP ²⁷. While residents working in private hospitals had the highest rates of low PA. The test showed a significant relation between the levels of burnout components and the residency program affiliated authority ⁵.

This study tested the relationship between burnout and end of rotation after COVID19. The result was end of rotation after COVID 19 had the highest rates of PA and all levels of training are high in PA. One of the studies revealed that the global prevalence of burnout syndrome among medical residents is high, proving that the threat posed by SARS-CoV-2 is a major stressor for medical staff ¹. While burnout and wellness statistics among radiologists, both attending and trainees, have been morbid in recent years, the onset of practices to combat COVID-19 has disrupted even those with otherwise stable personal wellness ²⁸. Although promising, physicians remain at heightened risk for burnout compared with other fields, and this may intensify due to COVID-19 ²⁹.

Finally, the current study also examined the correlation to determine the relation between independent variables with Burnout among trainees. The outcome reveals a medium positive correlation between Emotional exhaustion and Depersonalization, which means significant link between the emotional exhaustion, depersonalization with Burnout among trainees. In addition, result shows significant relationship between the dimensions of burnout and training level. In regards to smoking status and training level showed a significant relationship with the severity of burnout. One study concluding that the There was a strong correlation between EE and depressive symptoms, which is consistent with the results of a previous study ³⁰. Also supporting this result one of study revealed that Emotional exhaustion (EE) was the only burnout component strongly correlated with the severity of depression ³¹ and increased psychological demand was associated with higher emotional exhaustion and depersonalization ³².

11. Conclusion

The test result shows that the personal achievement has was impacted the mostly, which shows that the participants have less personal achievement, that is, less competence and successful achievement in one's work with people. Depersonalization comes as second affected dimension of burnout, that means unfeeling and impersonal response toward recipients of one's service & care, lastly emotional exhaustion was the third dimension in prevalence among the trainees. Finally, the Pearson correlation test result shows that significant link between the emotional exhaustion, depersonalization with Burnout among trainees.

12. Recommendations

This research recommending the health care leaders to evaluate area of concerns for improvement in the academic areas of healthcare organization.

Healthcare organizations should focus on the need of assessing trainee’s burnout as that will provide basic understanding of the perceptions of their burnout level during training periods. This assessment tools can help healthcare organizations of the training center in identifying the areas for improvement. However, further studies are required to include all healthcare training staff to identify their perception on burnout and strategies to reduce the burnout in their training periods in the healthcare settings.

13. Limitations of the Study

A limitation of this study was that the perceptions of all training members were not included. So, the result cannot be represented as a whole organizational level. The study relies on self-reported online survey and if using participant’s direct interview may get more ideas and recommendation on implementation of new interventions to reduce the burnout among resident’s trainees.

References