Levels of burnout and related factors in research assistant doctors working in a university hospital during the COVID-19 pandemic

Authors

Abstract

Aim This study aimed to evaluate the levels of burnout among resident physicians working at a faculty of medicine hospital during the COVID-19 pandemic and to identify potential factors associated with burnout.
Materials and Methods This research was designed as a cross-sectional survey study. The study population consisted of 250 resident physicians employed at the faculty of medicine hospital. Based on a review of the relevant literature, a questionnaire was developed comprising a personal information form and the Maslach Burnout Inventory (MBI). Data were analyzed using one-way ANOVA, Student’s t-test, and Pearson correlation analysis.
Results The mean scores of resident physicians on the subscales of the MBI were 19.00 ± 6.73 for Emotional Exhaustion, 7.62 ± 3.46 for Depersonalization, and 18.88 ± 4.27 for Personal Accomplishment. In terms of working conditions, residents who worked more than eight hours per day, were on-call, reported decreased job satisfaction during the pandemic, or were employed in internal medicine departments experienced significantly higher burnout. With respect to pandemic-related factors, those who actively participated in the management of COVID-19, worked in emergency or intensive care units, perceived the hospital’s physical conditions as inadequate, had direct contact with COVID-19 patients, underwent testing, received a diagnosis, or reported higher levels of concern about contracting COVID-19 themselves or transmitting it to family members also exhibited greater burnout.
Discussion Burnout syndrome was found to be highly prevalent among resident physicians working during the COVID-19 pandemic. To prevent more severe consequences for physicians, early interventions should focus on improving working conditions and providing appropriate counseling and support services.

Keywords

Introduction

Throughout history, humanity has faced various pandemics, including plague, cholera, the Spanish flu, and Human Immunodeficiency Virus (HIV) [1]. Coronavirus disease 2019 (COVID-19), first reported in the final months of 2019, was declared a pandemic on March 11, 2020. Due to its rapid spread and severe clinical outcomes in high-risk groups, COVID-19 has become a critical public health concern [2, 3]. During the pandemic, healthcare workers have been at the forefront of the response, undertaking substantial duties and responsibilities. Burnout syndrome was first defined by Maslach and Jackson in 1981 as “a syndrome characterized by physical exhaustion, prolonged fatigue, feelings of helplessness and hopelessness, and the manifestation of negative attitudes toward one’s work, life, and other people, observed particularly in individuals who are exposed to intense emotional demands due to their profession and who work continuously in face-to-face contact with others” [4]. Studies conducted prior to the pandemic consistently demonstrated high levels of burnout among resident physicians [5, 6, 7]. With the onset of the COVID-19 pandemic, the increased workload, prolonged use of personal protective equipment (PPE), and fears of becoming infected or transmitting the infection to family members have raised concerns about the extent of burnout experienced by healthcare workers during this period [8, 9].
The aim of this study was to assess the levels of burnout among resident physicians working during the COVID-19 pandemic and to investigate the factors potentially associated with burnout.

Materials and Methods

This study was designed as a cross-sectional survey conducted among resident physicians working at a university Faculty of Medicine Hospital during the COVID-19 pandemic. The study population consisted of 305 resident physicians enrolled in specialty training programs at the faculty of medicine hospital. No sampling method was applied, and it was aimed to include the entire population. After excluding those who declined participation and those with incomplete responses, a total of 250 resident physicians were included in the study.
Based on a review of the relevant literature, a survey questionnaire was developed [5, 10, 11, 12, 13]. The questionnaire consisted of two sections: a 43-item personal information form and the 22-item Maslach Burnout Inventory (MBI). Data were collected through face-to-face interviews between April 5 and July 5, 2021.
The personal information form included 43 questions covering the sociodemographic characteristics of the resident physicians, working conditions, and certain factors related to the COVID-19 pandemic that could potentially be associated with burnout.
The MBI comprises three subscales: Emotional Exhaustion (EE), Depersonalization (DP), and Personal Accomplishment (PA), encompassing a total of 22 items. EE includes 9 items, DP consists of 5 items, and PA contains 8 items [4]. The Turkish adaptation of the MBI was conducted by Ergin. Items on the scale are scored on a 5-point Likert scale as follows: never = 0, rarely = 1, sometimes = 2, often = 3, and always = 4. Accordingly, scores range from 0–36 for the EE subscale, 0–20 for the DP subscale, and 0–32 for the PA subscale [14].
The EE subscale reflects the extent to which an individual feels emotionally overextended and exhausted by their work, whereas the DP subscale includes negative statements describing an impersonal, detached, or indifferent attitude toward the recipients of one’s service. In contrast, the PA subscale consists of positive statements measuring an individual’s sense of competence and achievement in their professional life. Therefore, higher scores on the EE and DP subscales, coupled with lower scores on the PA subscale, indicate greater levels of burnout. Consequently, burnout is evaluated not by a single total score but through the three separate subscale scores [15]. In Ergin’s Turkish adaptation study of the MBI, the results of validity and reliability tests yielded Cronbach’s alpha coefficients of 0.83 for EE, 0.65 for DP, and 0.72 for PA [14]. In the present study, Cronbach’s alpha coefficients were 0.90 for EE, 0.74 for DP, and 0.79 for PA.
Data were analyzed using the SPSS 22 statistical software package. Descriptive statistics were presented as number (n), percentage (%), mean (X), standard deviation (SD), minimum (min.), and maximum (max.). To evaluate the relationships between groups and continuous variables, the Student’s t-test was applied for comparisons between two groups, and one- way analysis of variance (ANOVA) was used for comparisons involving more than two groups. Pearson correlation analysis was conducted to determine the direction and strength of relationships between numerical variables. A p-value of < 0.05 was considered statistically significant.
Ethical Approval This study was approved by the Ethics Committee of Kahramanmaraş Sütçü İmam University, Faculty of Medicine (Date: 2021-04-05, No: 07).

Results

A total of 250 resident physicians were included in the study. The mean age of the participants was 29.46 ± 3.61 years (range: 24–49). Of the participants, 54.8% were male, and 45.2% were female; 53.6% were married, and 32.4% had children. Regarding medical specialty, 67.6% of the resident physicians were working in internal medicine departments, 29.6% in surgical departments, and 2.8% in basic medical sciences. Among the participants, 20.8% reported smoking, and 8.8% reported alcohol consumption. More than half of the smokers (55.7%) indicated that their smoking habits had increased during the pandemic. Additionally, 68% of participants reported that the pandemic negatively affected their job satisfaction. Regarding COVID-19–related work, 89.6% of the resident physicians reported active involvement in COVID-19 patient care, 90% had direct contact with COVID-19 patients, 86.8% had undergone testing for COVID-19, and 31.2% had previously been diagnosed with COVID-19.
When examined according to the MBI subdimensions, the mean scores of the research assistant doctors were as follows: MBI- EE 19.00 ± 6.73 (0-36), MBI-DP 7.62 ± 3.46 (0-16), MBI-PA 18.88 ± 4.27 (8-31).
Female participants had lower mean scores on the PA subscale compared to male participants, and participants aged 24–29 had lower PA scores compared to those in older age groups (p < 0.05). Single participants exhibited higher mean scores on the EE subscale and lower PA scores compared to married participants (p < 0.05). Participants living alone had significantly lower PA scores compared to those living with a spouse and/or children, and resident physicians working in internal medicine departments had lower PA scores than those in surgical departments (p < 0.05).
Participants working more than eight hours per day and those on-call had significantly higher EE and DP scores compared to participants working eight hours or less and those not on-call (p < 0.05), while no significant difference was observed in PA scores between these groups.
Participants who reported decreased job satisfaction during the pandemic had significantly higher EE and DP scores and significantly lower PA scores (p < 0.05) (Supplementary Table S1).
Participants who were actively involved in COVID-19 patient care had higher mean scores on the DP subscale compared to those who were not actively involved (p < 0.05).
Resident physicians working in emergency and/or intensive care units had significantly higher mean scores on the EE and DP subscales compared to those working in other departments (p < 0.05). Similarly, participants with direct contact with COVID-19 patients, those who had previously undergone testing for COVID-19, and those with a prior COVID-19 diagnosis exhibited significantly higher EE and DP scores compared to participants without such experiences (p < 0.05).
Participants who reported high levels of concern about contracting COVID-19 had significantly higher EE scores and significantly lower PA scores (p < 0.05).
When asked about concerns of transmitting COVID-19 to household members after work, participants with high levels of concern had significantly higher EE scores compared to those with moderate or low concern levels (p < 0.05).
Participants who perceived the hospital’s physical conditions as inadequate had significantly higher EE and DP scores and significantly lower PA scores (p < 0.05) (Supplementary Table S2).
Pearson correlation analysis was conducted to examine the relationships between numerical variables and the MBI subscale scores. Age was found to have a very weak negative correlation with DP scores and a weak positive correlation with PA scores. The duration of professional experience as a physician showed a weak positive correlation with PA scores, as did the duration of residency training.
The number of on-call shifts in one month was weakly positively correlated with EE scores and very weakly positively correlated with DP scores. Additionally, prior on-call experience was weakly positively correlated with PA scores (Supplementary Table S3).

Discussion

Burnout syndrome is an occupational condition particularly observed in individuals who work in direct, face-to-face contact with others. Chronic stress present in the work environment plays a central role in the development of burnout [16, 17]. In addition to the stress that healthcare workers already experience due to challenging working conditions, the COVID-19 pandemic introduced new stressors [18].
In a 2006 study conducted by Çan et al. involving 192 resident physicians, it was reported that those working in surgical departments had higher levels of EE [19]. Similarly, Bertges et al. (2005) found elevated EE and DP scores among physicians working in surgical units [20]. In our study, however, no significant differences were observed in EE and DP scores when resident physicians were compared according to their department. This lack of difference may be attributable to the fact that physicians across all specialties were actively involved in the management of COVID-19, resulting in uniformly elevated stress levels.
In a study conducted by Akalın and Modanlıoğlu involving healthcare professionals working in intensive care units, employees who reported decreased job satisfaction during the COVID-19 pandemic were found to have higher levels of burnout [21]. In our study, participants whose job satisfaction was negatively affected during the pandemic exhibited higher levels of burnout across all three MBI subscales. This outcome may be attributed to increased workload during the pandemic. Additionally, as our study population consisted exclusively of resident physicians, factors such as the temporary closure of outpatient clinics, suspension of elective surgeries, the assignment of COVID-19 patient care over specialty-specific patients, and remote specialty training may have disrupted residency education, contributing to decreased job satisfaction. Contrary to the findings of Wu et al. and Dinibütün (2020), which reported that healthcare workers actively involved in pandemic response experienced lower levels of burnout [12, 22]. Our study found that resident physicians who actively participated in COVID-19 patient care exhibited higher DP scores compared to those who did not. No significant differences were observed in EE or PA scores. Unlike these previous studies, our research was conducted approximately one year after the onset of the pandemic; therefore, even physicians not actively involved may have had greater knowledge and familiarity with COVID-19 than during the early stages, which may have mitigated differences in PA scores. We hypothesize that the increased depersonalization among resident physicians actively engaged in pandemic response may reflect a psychological defense mechanism developed to cope with stress encountered during the treatment of COVID-19 patients.
In a study conducted by Atilla and Karakaya, healthcare
workers employed in emergency, intensive care, and surgical departments were found to experience higher levels of burnout during the COVID-19 pandemic [23]. Similarly, in our study, resident physicians working in emergency and/or intensive care units exhibited higher scores on the EE and DP subscales compared to those working in other departments. COVID-19 patients receiving care in emergency or intensive care settings typically present with more severe clinical conditions compared to those treated in outpatient clinics, wards, or community- based services (e.g., home healthcare, contact tracing), resulting in higher mortality rates. Factors such as heavy workloads, prolonged exposure to COVID-19 patients during treatment, and witnessing patient deaths despite comprehensive medical interventions may have contributed to increased burnout among resident physicians in these departments. The results of our study are consistent with the literature, supporting a positive association between the level of concern about becoming infected or transmitting the infection to family members and burnout [18, 24, 25].
In our study, no significant relationship was observed between living with individuals at high risk for COVID-19 and burnout levels. This finding may be explained by the fact that COVID-19 vaccination had already been initiated for high-risk individuals at the time of data collection.
Several studies have emphasized that the lack of personal protective equipment (PPE) and difficulties in accessing PPE contribute to burnout among healthcare workers [18]. Consistently, in our study, resident physicians who perceived the hospital’s physical conditions as inadequate experienced higher levels of burnout. This may be attributed to working in a high- risk, insufficiently protective environment during the highly contagious COVID-19 pandemic, which could evoke feelings of insecurity and vulnerability.
Resident physicians with direct contact with COVID-19 patients and those who had undergone testing for COVID-19 exhibited higher scores on the EE and DP subscales. This finding may be explained by prolonged and close interactions with COVID-19 patients, resulting in increased exposure risk and workload, as well as heightened fear of infection, death, and transmitting the virus to family members.
Analysis of numerical variables revealed that increased age, longer professional experience, and higher years of residency training were associated with lower burnout levels, suggesting a potential protective effect. Furthermore, prior on-call experience appeared to have a modest protective role, whereas an increased number of monthly on-call shifts may constitute a potential risk factor for burnout.

Limitations

This study has several methodological limitations. Conducting the research in a single center restricts the generalizability of the findings to different institutional settings. The reliance on self-reported data increases the potential for measurement bias due to respondent tendencies. Rapidly changing clinical and organizational conditions during the pandemic could not be controlled systematically; therefore, some external factors may not have been fully captured in the analysis. Moreover, the cross-sectional design precludes causal inferences regarding the associations between burnout and related factors. Despite these limitations, the study provides valuable insight into the determinants of burnout among junior physicians during the pandemic.

Conclusion

This study revealed the burnout levels of resident physicians working during the COVID-19 pandemic and identified factors influencing these levels. The findings indicate that burnout was significantly higher among physicians actively working in emergency and intensive care units, those with direct contact with COVID-19 patients, and those who had undergone testing or received a COVID-19 diagnosis. Additionally, burnout levels were markedly elevated among resident physicians who reported high levels of concern about infection, feared transmitting the disease to cohabitants, or perceived the physical conditions of their workplace as inadequate. These results suggest that the pandemic imposed not only increased professional demands but also substantial psychosocial burdens on young physicians. Based on the findings of this study, the following interventions are considered critical to reduce burnout among resident physicians:
• Improving working conditions and ensuring a balanced distribution of workload,
• Ensuring uninterrupted provision of personal protective equipment (PPE),
• Expanding and enhancing accessibility to psychosocial support services,
• Strengthening education and communication regarding infection risks, preventive measures, and vaccination processes,
• Providing isolation and accommodation facilities,
• Developing sustainable healthcare policies tailored to crisis periods.
These measures are expected to contribute not only to the reduction of burnout levels among resident physicians but also to the resilience of healthcare services during public health crises.

References

1. Morens DM, Daszak P, Markel H, Taubenberger JK. Pandemic COVID-19 joins history’s pandemic legion. ASM Journals mBio. 2020;11(3):e00812-20. doi:10.1128/mbio.00812-20.
   Article PubMed Google Scholar
2. Beyoğlu A, Beyoğlu MM. The effect of online education during the pandemic on ocular surface symptoms. JOSAM. 2021;5(9):928-31. doi:10.28982/ josam.989477.
   Article PubMed Google Scholar
3. Beyoğlu M, Erdoğan A. Exposure to Violence, psychological resilience and burnout in filiation workers in the COVID-19 pandemic. Gevher Nesibe J Med Health Sci. 2022;7(21):160-7. doi:10.5281/zenodo.7392821.
   Article PubMed Google Scholar
4. Maslach C, Jackson SE. The measurement of experienced burnout. J Organ Behav. 1981;2(2):99-113. doi:10.1002/job.4030020205.
   Article PubMed Google Scholar
5. Can H, Güçlü YA, Doğan S, Erkaleli MB. Cerrahi ve cerrahi dışı kliniklerdeki asistan hekimlerde tükenmişlik sendromu. [Burnout syndrome among resident physicians in surgical and non-surgical clinics]. İzmir Tepecik Eğitim Hastanesi Derg. 2010;20(1):33-40. doi:10.5222/terh.2010.25307.
   Article PubMed Google Scholar
6. Dabak R, Özçınar M, Sargın M, Tamer İ, Orbay E. Burnout syndrome among residents. Turk J Fam Pract. 2007;11(2):67-71.
   PubMed Google Scholar
7. Kansoun Z, Boyer L, Hodgkinson M, Villes V, Lançon C, Fond G. Burnout in French physicians: a systematic review and meta-analysis. J Affect Disord. 2019;246:132-47. doi:10.1016/j.jad.2018.12.056.
   Article PubMed Google Scholar
8. Sakaoğlu HH, Orbatu D, Emiroglu M, Çakır Ö. Covid-19 salgını sırasında sağlık çalışanlarında Spielberger durumluk ve sürekli kaygı düzeyi: Tepecik Hastanesi örneği. [Spielberger state and trait anxiety level in healthcare professionals during the Covid-19 outbreak: a case of Tepecik Hospital]. Tepecik Egit Arast Hast Derg. 2020;30:1-9. doi:10.5222/terh.2020.56873.
   Article PubMed Google Scholar
9. Yılmaz BK, Güler ME, Dalkılıç OS. Sağlık çalışanlarının Covid-19 küresel salgınına bakış açılarının ve tutumlarının değerlendirilmesi. [Evaluation of healthcare workers’ perspectives and attitudes toward the COVID-19 pandemic]. J Yasar Univ. 2021;16(62):960-81. doi:10.19168/jyasar.862327.
   Article PubMed Google Scholar
10. Ardıç K, Polatcı S. Tükenmişlik sendromu akademisyenler üzerinde bir uygulama (GOÜ örneği). [An analysis of burnout syndrome among academicians: the Gaziosmanpaşa University case]. Gazi Univ Iktisadi Idari Bilimler Fak Derg. 2008;10(2):69-96.
    PubMed Google Scholar
11. Arpacıoğlu S, Baltalı Z, Ünübol B. COVID-19 pandemisinde sağlık çalışanlarında tükenmişlik, Covid korkusu, depresyon, mesleki doyum düzeyleri ve ilişkili faktörler. [Burnout, fear of COVID-19, depression, job satisfaction levels, and associated factors among healthcare workers during the COVID-19 pandemic]. Cukurova Med J. 2021;46(1):88-100. doi:10.17826/cumj.785609.
    Article PubMed Google Scholar
12. Dinibütün SR. Factors associated with burnout among physicians: an evaluation during a period of COVID-19 pandemic. J Healthc Leadersh. 2020;12:85-94. doi:10.2147/JHL.S270440.
    Article PubMed Google Scholar
13. Matsuo T, Kobayashi D, Taki F, et al. Prevalence of health care worker burnout during the Coronavirus disease 2019 (COVID-19) pandemic in Japan. JAMA Netw Open. 2020;3(8):e2017271. doi:10.1001/jamanetworkopen.2020.17271.
    Article PubMed Google Scholar
14. Ergin C. Doktor ve Hemşirelerde Tükenmişlik ve Maslach Tükenmişlik Ölçeğinin Uyarlanması. [Burnout among physicians and nurses and the adaptation of the Maslach Burnout Inventory]. VII Ulusal Psikol Kongr Bilimsel Calismalari: 7 Ulusal Psikol Kongr Duzenleme Kurulu Turk Psikologlar Dernegi Yay. 1992.
    PubMed Google Scholar
15. Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol. 2001;52:397-422. doi:10.1146/annurev.psych.52.1.397.
    Article PubMed Google Scholar
16. Freudenberger HJ. Staff Burnout. J Soc Issues. 1974;30(1):159-65. doi:10.1111/j.1540-4560.1974.tb00706.x.
    Article PubMed Google Scholar
17. Kumar VK, Weil PD. The truth about burnout: how organizations cause personal stress and what to do about it. Pers Psychol. 1998;51(2):542-46.
    PubMed Google Scholar
18. Bradley M, Chahar P. Burnout of healthcare providers during COVID-19. Cleve Clin J Med. 2020. doi:10.3949/ccjm.87a.ccc051.
    Article PubMed Google Scholar
19. Çan E, Topbaş M, Yavuzyılmaz A, Çan G, Özgün Ş. Karadeniz teknik üniversitesi tıp fakültesindeki araştırma görevlisi hekimlerin tükenmişlik sendromu ile iş doyumu düzeleri ve ilişkili faktörler. [Burnout syndrome, job satisfaction levels, and associated factors among resident physicians at Karadeniz Technical University Faculty of Medicine]. J Exp Clin Med. 2006;23(1):17-24.
    PubMed Google Scholar
20. Bertges Yost W, Eshelman A, Raoufi M, Abouljoud MS. A national study of burnout among American transplant surgeons. Transplant Proc. 2005;37(2):1399-401. doi:10.1016/j.transproceed.2005.01.055.
    Article PubMed Google Scholar
21. Akalın B, Modanlıoğlu A. Covid-19 sürecinde yoğun bakımda çalışan sağlık profesyonellerinin duygu-durum ve tükenmişlik düzeylerinin değerlendirilmesi. [Evaluation of mood and burnout levels among healthcare professionals working in intensive care units during the COVID-19 period]. Acibadem Univ Saglik Bilim Derg. 2021;12(2):346-52. doi:10.31067/acusaglik.850978.
    Article PubMed Google Scholar
22. Wu Y, Wang J, Luo C, et al. A comparison of burnout frequency among oncology physicians and nurses working on the frontline and usual wards during the COVID-19 epidemic in Wuhan, China. J Pain Symptom Manage. 2020;60(1):e60-5. doi:10.1016/j.jpainsymman.2020.04.008.
    Article PubMed Google Scholar
23. Atilla EA, Karakaya A. Covid-19 pandemi döneminin sağlık çalışanlarının tükenmişlik düzeylerine etkisi. [The impact of the COVID-19 pandemic period on burnout levels among healthcare workers]. Ankara Haci Bayram Veli Univ Iktisadi Idari Bilimler Fak Derg. 2021;23(3):653-80. doi:10.26745/ahbvuibfd.989594.
    Article PubMed Google Scholar
24. Hoşgör DG, Tanyel TÇ, Cin S, Demirsoy SB. COVID-19 pandemisi döneminde sağlık çalışanlarında tükenmişlik: İstanbul ili örneği. [Burnout among healthcare workers during the COVID-19 pandemic: The case of Istanbul]. Avrasya Sosyal Ekon Arast Derg. 2021;8(2):372-86.
    PubMed Google Scholar
25. Temsah MH, Al-Sohime F, Alamro N, et al. The psychological impact of COVID-19 pandemic on health care workers in a MERS-CoV endemic country. J Infect Public Health. 2020;13(6):877-82. doi:10.1016/j.jiph.2020.05.021.
    Article PubMed Google Scholar

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