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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 27  |  Issue : 3  |  Page : 215-223

Assessment of burnout amongst resident doctors in Benin City, Edo State, Nigeria


1 Department of Community Health, University of Benin Teaching Hospital; Department of Community Health, University of Benin, Benin City, Edo State, Nigeria
2 Department of Community Health, University of Benin, Benin City, Edo State, Nigeria

Date of Submission18-Feb-2020
Date of Decision13-May-2020
Date of Acceptance17-May-2020
Date of Web Publication17-Jul-2020

Correspondence Address:
Dr. Esohe Olivia Ogboghodo
Department of Community Health, College of Medical Sciences, University of Benin, PMB 1154, Benin City, Edo State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/npmj.npmj_37_20

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  Abstract 


Background: Burnout amongst healthcare professionals has gained significant attention over the last few decades. As a result of the intense demand from the work environment, clinicians are susceptible to developing burnout beyond the usual workplace stress. Residency training, in particular, can cause significant degree of burnout. Aim: The aim was to determine the prevalence and pattern of burnout amongst resident doctors in Benin City. Materials and Methods: This study utilised a descriptive, cross-sectional study design. A total population study was carried out amongst resident doctors in Benin City. The tool for data collection was a pretested Maslach Burnout Inventory Questionnaire–Human Services Survey for Medical Personnel. Data were analysed with IBM SPSS version 22.0 software. The level of significance was set at P < 0.05. Results: A total of 448 resident doctors with a mean age (standard deviation) of 33.9 ± 0.4 years participated in this study. A higher proportion (279, 62.3%) of the respondents were males. A total of 267 (59.6%) respondents suffered emotional exhaustion (EE), while depersonalisation and reduced personal accomplishments were suffered amongst 211 (47.1%) and 153 (34.2%), respectively. The overall prevalence of burnout was 41.7%. Long duration of call hours (P < 0.001) and speciality (P = 0.039) were found to be significantly associated with burnout. Conclusion: Burnout was prevalent amongst resident doctors in Benin City. EE was the most reported type. There is a need for relevant stakeholders to re-structure the residency programme by reducing the duration of call hours and increasing the number of resident doctors on call per shift to further address modifiable risks amongst the would-be specialists.

Keywords: Benin City, burnout, emotional exhaustion, residency


How to cite this article:
Ogboghodo EO, Edema OM. Assessment of burnout amongst resident doctors in Benin City, Edo State, Nigeria. Niger Postgrad Med J 2020;27:215-23

How to cite this URL:
Ogboghodo EO, Edema OM. Assessment of burnout amongst resident doctors in Benin City, Edo State, Nigeria. Niger Postgrad Med J [serial online] 2020 [cited 2020 Aug 11];27:215-23. Available from: http://www.npmj.org/text.asp?2020/27/3/215/289911




  Introduction Top


Burnout is a public health problem with consequences that occurs when the demand in the workplace is unusually high, and it becomes increasingly impossible to cope with the stress associated with these working conditions.[1],[2] The World Health Organization (WHO) defines burnout as a syndrome resulting from chronic workplace stress that has not been successfully managed.[3] The risk factors for burnout include individual factors such as poor self-esteem and excessive shyness; organisational factors such as heavy workload, understaffing, unrealistic high expectations and diminished resources; critical care factors such as rapid turnover of patients and end-of-life events.[2],[4]

Burnout usually occurs in four stages.[5] The first is a stage of high workload, high job stress and high job expectations where the job demands exceed the resources available and individual expectations are not fulfilled. The second stage is physical exhaustion and emotional exhaustion (EE) usually characterised by chronic physical exhaustion, sleep disturbances, headaches and EE. Stage 3 is a stage of depersonalisation (DP) and cynicism characterised by a negative attitude towards the job, colleagues and clients, resulting in gradual reduction in work efforts and withdrawal from the job. The final stage is a stage of despair and helplessness characterised by aversion to oneself and people with a feeling of guilt and insufficiency.[5]

Burnout has three types; EE, DP and reduced personal accomplishments (PAs). EE occurs due to fatigue occurring due to excess effort and time put into tasks not perceived to be beneficial. DP manifests as negative, callous and cynical behaviours, while reduced PAs manifests as negative evaluation of the worth of work, feeling insufficient in the ability to perform and generalised poor self-esteem.[4]

The residency training programme in Nigeria was formally established in 1974, with the objective of providing specialist training at a high level and halting brain drain taking place as a result of relocation of the much-needed medical specialists to the developed world.[6],[7],[8] The National Postgraduate Medical College of Nigeria (NPMCN) and the West African College of Physicians and Surgeons are the postgraduate medical colleges responsible for training medical doctors and dentists undergoing specialisation in the country. The West African College of Physicians was established in 1976 following which the NPMCN was established in 1979 by the National Postgraduate Medical College Decree.[9] The three main examinations that residents have to take to become full specialists/consultants are the Primaries, Part I and Part 2 examinations.[10] It is upon the completion of the Part 2 examination that they are awarded the fellowship of any of the respective colleges. The causes and progress of burnout amongst all doctors have not yet been fully explained,[11] and the levels amongst resident doctors have become epidemic, with a prevalence being twice as frequent as in other professions ranging from 25.0% to 65.0% in France[12] and 76.0% amongst residents in the US.[13],[14] In Nigeria, the prevalence of burnout ranges from 31.6% to 45.6% reported between 2014 and 2016 in Oyo,[15] Lagos[16] and Jos.[17] Till date, there have been limited studies that have reported a prevalence amongst resident doctors in Benin City, hence the relevance of the study. The objectives of this study were to determine the prevalence and determinants of burnout amongst the resident doctors in Benin City. This study will help increase the existing body of knowledge on the prevalence of burnout amongst resident doctors in hospitals. Such information will be useful in planning preventive health services for resident doctors, which will in turn improve the end quality of care received by patients.


  Materials and Methods Top


This study which utilised a descriptive, cross-sectional study design was carried out amongst resident doctors in Benin City, Edo State. Six hospitals offered residency training in Benin City, viz. University of Benin Teaching Hospital (UBTH), Federal Neuropsychiatry Hospital, Central Hospital, Lily Hospital, Echos Specialist Hospital and Faith Mediplex Hospital. The total population of resident doctors in Benin City was 461. Data were collected between 15th November 2019 and 15th January 2020.

A minimum sample size of 423 was gotten using the formula for single proportion (n =.[18] This was calculated considering a standard normal deviate of 1.96 at a significance level of 5%, degree of precision of 5%, 51.7% (proportion of burnout amongst resident doctors in Igbobi, Lagos, Nigeria)[19] and a 10% attrition rate (nonresponse).

Taking p to be 0.517; ;n n= 383.7 ≈ 384.

A 10% non-response rate was calculated and added to account for lost or unfilled questionnaires.

That is , =38.4; Final sample size =384 + 38.4 = 422.4 ≈ 423

However, a total population study was carried out.

Data were collected using the 22-item Maslach Burnout Inventory (MBI)–Human Services Survey for Medical Personnel scale,[20] which is recognised as the leading measure of burnout in 88.0% of publications, validated by over 35 years of extensive research. The tool measures burnout as defined by the WHO[21] and covers the three areas for EE, DP and low sense of PA.[20] Various psychometric analyses have shown that the MBI scale has both high reliability and validity as a measure of burnout and its use is widely supported.[22]

Ethical clearance (protocol number ADM/E 22/A/VOL.VII/148204) was obtained on the 4th November 2019 from the Ethics and Research Committee, UBTH, PMB 1111, Benin City, Edo State, Nigeria. A pre-test of the study tool was conducted amongst 45 resident doctors in Irrua Specialist Teaching Hospital, Irrua, Edo State. Pre-testing was done to enhance clarity, comprehensibility, validity and reliability of data tool, and corrections were effected before commencement of the study. Permission was obtained from the hospitals that offer residency training in Benin City and from the President of the Association of Resident Doctors. Permission was also gotten from the chief resident in every speciality before the commencement of the study. Data collection began with UBTH; thereafter, questionnaires were taken to the other facilities. Resident doctors in respective specialities that had daily and weekly clinical meetings were approached politely after a meeting and were informed about the study, while specialities with residents who did not hold regular clinical meetings were met individually during work hours. Thereafter, informed consent was obtained and each resident doctor was given a questionnaire which was collected from them at the clinical meeting of the following day or week. This ensured privacy and confidentiality in filling the questionnaires. Furthermore, serial numbers rather than names were used to identify the respondents. Respondents were informed that they had the right to decline participation or to withdraw from the study at any time they wished. All data were kept secure and made available only to members of the research team (two researchers and two research assistants).

The questionnaires were collated, screened for completeness, numbered serially and entered into IBM SPSS Statistics for Windows, Version 22.0, Armonk, NY: IBM Corp. The MBI questionnaire assessed the prevalence of burnout using 22 questions with a 7 point graded scale of never (0), a few times a year or less (1), once a month or less (2), a few times a month (3), once a week (4), a few times a week (5), or every day (6). A maximum score of 6 and a minimum score of 0 were given for every response. A total of nine questions assessed EE which gave a maximum score of 54. Respondents with scores >27 were interpreted as being emotionally exhausted. DP was assessed using a total of five questions which gave a maximum score of 30. Respondents with scores >10 were interpreted as being depersonalised. PAs was assessed using a total of eight questions which gave a maximum score of 48. A score <33 amongst respondents was interpreted as low sense of PA. Overall burnout scores were computed using EE, PA and DP such that any respondent who had at least one of the types of burnout was regarded to be burnt-out.[23] Univariate analysis was done to assess the distribution of variables. Chi-square test and Fishers' exact test (used when the total number of expected cells <5 were more than 25%) were used to test the association between age group, sex, residency training characteristics and burnout. Multivariate analysis was done using binary logistic regression to further determine the significant predictors of burnout. The level of significance was set at P < 0.05. Results obtained were presented using frequency tables and cross-tabulations.


  Results Top


There were a total number of 448 respondents with a response rate of 97% from the total of 461 resident doctors. The mean age was 33.9 (4.0) years. A higher proportion (212, 47.3%) were aged 31–35 years followed by 120 (26.8%) aged 36–40 years. A higher proportion were males (62.3%), and a higher proportion (312, 69.7%) were married. Majority (397, 88.6%) of the resident doctors were training in the UBTH. Faith Medical Centre and Echos Hospital had the least proportion of resident doctors with 5 (1.2%) and 3 (0.6%), respectively [Table 1].
Table 1: Sociodemographic characteristics of resident doctors in Benin City (n=448)

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A slightly higher proportion (229, 51.1%) were residents in medicine-related specialities while 219 (48.9%) were in surgery-related specialities. Majority (324, 72.3%) were junior registrars while the highest proportion (138, 30.8%) had spent 1–2 years in the residency programme. About a third, 152 (33.9%), had 24–48 h of call per week while 130 (29.0%) and 118 (26.4%) had <24 h and 48–72 h, respectively. Respondents who had weekly call hours >72 h had the least proportion 48 (10.7%) [Table 2].
Table 2: Residency training characteristics of resident doctors in Benin City (n=448)

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All parameters used to assess burnout of resident doctors are outlined in [Table 3]. About two-fifth 187 (41.7%) of the residents were burnt-out. A total of 267 (59.6%) were emotionally exhausted, 211 (47.1%) were depersonalised, while 153 (34.2%) had low sense of PAs [Table 4]. All 2 (100.0%) and 65 (48.5%) of divorced and single resident doctors, respectively, were burnt-out, while a lesser proportion (120, 38.5%) of the married residents experienced burnout. The association between marital status and burnout was statistically significant (P = 0.025) [Table 5].
Table 3: Maslach Burnout Inventory-Human Services Survey for Medical Personnel

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Table 4: Prevalence and pattern of burnout amongst resident doctors in Benin City

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Table 5: Association between sociodemographic characteristics and burnout amongst resident doctors in Benin city

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A higher proportion (34, 70.8%) of the resident doctors who had more than 72 h call duty weekly were burnt-out. The association between weekly call hours and burnout was statistically significant (P < 0.001). A higher proportion (51, 54.3%) of the residents who had spent 2–4 years in the residency programme were burnt-out as compared to the residents who had spent 1–2 years 53 (38.4%) and >4 years 37 (35.2%). The association between residency duration and burnout was statistically significant (P = 0.036) [Table 6].
Table 6: Association between residency training characteristics and burnout amongst resident doctors in Benin City

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In the surgical specialities, a highest proportion of 41 (51.9%) residents in surgery and a least proportion of 1 (2.3%) in dentistry experienced burnout. The association between surgical specialities and burnout was statistically significant (P < 0.001). In the medical specialities, a higher proportion of 11 (68.8%) residents in psychiatry and a least proportion of 2 (22.2%) in community medicine experienced burnout. The association between medical specialities and burnout was statistically significant (P < 0.001) [Table 6].

A higher proportion 109 (47.4%) of residents in medicine-related specialities were burnt-out compared with 78 (35.8%) of the residents in surgery-related specialities. The association between speciality and burnout was statistically significant (P = 0.013). A slightly higher proportion 138 (42.6%) of junior residents and 49 (39.5%) of senior residents were experiencing burnout. The association between residency level and burnout was not statistically significant (P = 0.555) [Table 6].

A year increase in age increased the levels of burnout by 0.015 which was more likely by an odds ratio of 1.015 as compared to those who were not burnt-out (P = 0.641). Being male reduced the levels of burnout by 0.178 which was more likely by an odds ratio of 0.837 when compared to being female. This association was not statistically significant (P = 0.470). Being a senior registrar reduced the levels of burnout by 0.476 which was more likely by an odds ratio of 0.621 when compared to junior registrars. This association was not statistically significant (P = 0.208). Being in a medically-related speciality increased the burnout levels by 0.296 which was more likely by an odds ratio of 1.344 when compared to resident doctors in surgically-related specialities. This association was not statistically significant (P = 0.580). Short call hour period decreased the levels of burnout by 0.619 which was more likely by an odds ratio of 1.857 when compared to long call hours. This association was statistically significant (P < 0.001) [Table 7].
Table 7: Logistic regression model for determinants of burnout amongst resident doctors

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  Discussion Top


The socio-demographic findings in this study showed a mean age of 33.9 years, with a higher proportion of the respondents aged 31–35 years. This is similar to a study carried out in 2010 in Onabisi Onabanjo University, Ogun State,[24] where the mean age was 35.7 years with majority of respondents falling into age group of 31–47 years. This may be due to the cumulative years spent before residency (internship and youth corps) and the competitive nature of securing a placement in limited residency slots in Nigeria.

A greater proportion of the respondents were found to be males. This is similar to the findings from a study carried out in 2018 in Lagos[10] and in contrast with the studies done in 2015 in Singapore.[25] This may be because female doctors do not readily go in for residency training because they are saddled with the responsibility of home-making and family welfare. Often times, females remain general private practitioners and end up working in private hospitals where the scheduling and work hours are convenient to run their homes.[26]

Majority of the respondents were married. This is similar to the findings from a survey carried out in Malawi in 2017[27] and in contrast to the studies done in 2011 in India[28] and in UCH, Ibadan,[15] in 2016 where a higher proportion of the respondents were single. It can be speculated that our cultural and societal norms have influenced this as “frowns” are usually cast at individuals who have not settled down, despite admirable progress in their respective career or professions which is quite different from the Western culture. While it can be argued that being married is a source of succour and companionship, it however translates to more responsibilities. Doctors who are single will be more focussed, less pressured and more dedicated to their work.[29] On the other hand, having a partner may also play an important role in reducing the amount of burdens that the individual resident doctor will have to bear alone.[30]

Majority of the respondents were junior registrars. This is similar to a study carried out in 2016 in Ibadan[15] and in contrast with findings from a study carried out in 2018 in LUTH, Lagos,[10] which had a higher proportion of senior registrars. A higher proportion of the residents had spent 1–2 years in training. This is in keeping with the studies carried out in 2013 in Malaysia[31] and also in 2017 in Maharashtra, India,[32] and in contrast with the findings from a cross-sectional online survey amongst residents in 2018 in a large university hospital in Belgium,[33] where majority of the respondents had spent less than a year in the residency training programme. This may be due to the yearly increase in medical graduates all over the country who apply for residency. While this is comforting due to the high patient–doctor ratio, the other side of the coin would be a relative inexperience in patient care and health service delivery and, in the long run, delivery of suboptimal patient care.[34]

A greater proportion of the residents had call hours of 24–48 h. This is in contrast to the findings from a study carried out in 2013 in Taiwan, where majority of the respondents working 8–12 h per shift.[35] This contrast might be due to some factors such as difference in hospital policies and management regulations, strength of the workforce and patient load. However, there had been no official limit and monitoring on work hours of residency training programme in Nigeria.[24] The duration of call hours of a doctor has effects on his/her overall performance in his/her training and also on patient care as long call hours gradually reduce the efficiency of healthcare delivered. Majority of respondents who had more than 72 h of weekly call were burnt-out. This is in keeping with a study done in 2015 in Singapore[25] where doctors who had more than 60 working hours were 9.02 times more at risk of burnout compared to those working for 40 h. Call hours entail physicians staying alert throughout the night and attending to patients' needs and possible emergencies. Often times, the call hours spill over to the morning where the residents with few or no hours of sleep have to present cases seen over the call to senior colleagues or even participate in the ward rounds and unit activities. A repetition of this stressful work cycle can lead to under productivity; hence, this calls for a review of call schedules.[36]

This study revealed that 41.7% were experiencing burnout. This is higher than the studies carried out in 2015 in Jos, Plateau,[17] in 2015 in Mumbai, India,[37] and in 2018 in the Netherlands,[33] where those experiencing burnout ranged between 15.0% and 37.3%. This could possibly be attributed to the massive emigration of doctors, thus leaving fewer doctors to cope with the challenges of serving the populace in the background of a poor doctor-to-patient ratio. The advantage of technological advancement, adequate financing of the health sector and remuneration for health staff in advanced settings also provides a more conducive and encouraging environment to practice.[38] The increasing work burden on the resident doctors puts them at high risk for physical and emotional ailment, which would in turn have negative effects on the quality of patient care they render daily.

EE was the most reported pattern of burnout amongst over half of the resident doctors. This is in contrast to the studies done in 2012 in Igbobi, Lagos,[19] and in Jos[12] in 2015, where depersonalisation was the most reported pattern. EE can lead to decline in executive function, attention, memory and result in negative effects on work and personal relationships.[39] It can also result in psychological disorders such as insomnia, depression and mental illness and occupational consequences, which include job dissatisfaction and absenteeism.[40]

Burnout was more amongst the female resident doctors. This is similar to the findings from studies conducted in 2016 in UCH, Ibadan,[15] and in 2018 in the US.[41] This may be because of the increased responsibility and the roles a female has to play as a wife, mother and home-maker. Indeed, increased susceptibility to illness, high levels of stress and exhaustion are prices the female in the 21st century has to pay if she has decided to pursue a professional career and have a family. This should not be a scare or discouragement but a wakeup call to stakeholders for appropriate intervention.[42]

Burnout was more amongst single and separated respondents. This is in contrast to a study done in 2016 in the UCH, Ibadan,[15] where burnout was more amongst married respondents. Being single deprives the resident doctors of the physical, emotional and social support that they may require at home to adequately deal with the excessive demands and strain of work. Residents training in a medical-related speciality were more burnt out than residents in surgical-related specialities. This is in contrast to findings in 2016 in UCH[15] where residents in a surgical-related speciality were more burnt-out. Medical resident doctors usually spend longer duration in the management of chronic illnesses and are more subjected with the responsibility of end-of-life care, and this may put them at risk of burnout due to overwork and imbalance of personal and professional life.[43]

Findings from this study revealed that burnout was more amongst residents in their 2nd–4th year of residency when compared to those who had spent 1–2 and >4 years. This is in contrast to a study done in 2011 in India[28] where burnout was more amongst 1st-year residents. This may be due to the fact that the time duration between 2 and 4 years is when the junior residents take their Part 1 examinations and have to combine examination preparation and the increasing work demands. Residents who have spent more than 4 years are usually senior residents who at this time have junior resident doctors who work under them, so they have the ability to assign duties to the younger residents. Furthermore, residents who had spent 1–2 years have a lesser prevalence of burnout probably because they work mainly under supervision and may not be overburdened with the responsibility of managing all cases encountered, as compared to residents preparing for their professional examinations. Junior residents were slightly more burnt-out than senior residents and this was not statistically significant. This is similar to findings from a study in 2011 in India.[28] This could be due to less clinical experience which would require high skill, more workload, more hours of work, reduced sleep and intimidation from senior colleagues[28] and translates to a reduced quality in patient care and cynicism.

Respondents in surgery and psychiatry had the highest levels of burnout in surgically-related speciality and medically-related speciality, respectively. This is similar to a study done in 2015 in Mumbai.[37] This may largely be due to emotional and psychological exertions expended in the above fields. This exposes resident doctors in these fields to increasing risk of depression, especially in patients with cases of disease recurrences, relapses and death.


  Conclusion Top


Almost half of the resident doctors in Benin City experienced burnout, and EE was the most reported type in over half of them. Duration of call hours was the factor identified to be associated with increasing levels of burnout.

A national policy on the maximum number of weekly call hours should be written and signed into law. Resident doctors in various hospitals should be screened regularly for burnout and burnout management clinics instituted nationwide.

Acknowledgement

The authors wish to acknowledge the resident doctors who participated in the study.

Financial support and sponsorship

Nil.

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]



 

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