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ORIGINAL ARTICLE
Year : 2023 | Volume
: 11
| Issue : 1 | Page : 54-59
Burnout among ICU healthcare workers at two tertiary care hospitals in Makkah during the Hajj Season
Asia Rugaan1, Tharwat Aisa1, Kasim H Alkhatib2, Moamen Abdel Baky1, Faisal Al Tatar1, Ibrahim Ramadan1, Soha Elmorsy1, Adel Hussein1
1 Department of Adult Critical Care Medicine, King Abdullah Medical City, Makkah, Saudi Arabia
2 Department of Adult Critical Care Medicine, Al Noor Specialist Hospital, Makkah, Saudi Arabia
Correspondence Address:
Asia Rugaan
Department of Adult Critical Care, King Abdullah Medical City, Makkah 21955
Saudi Arabia
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/sjmms.sjmms_199_21
Background: The Hajj season results in increased workload and longer shift hours for healthcare workers at the intensive care units (ICUs), which may result in burnout.
Objective: To determine the point prevalence of professional burnout and its predictors among healthcare workers at the ICUs of two tertiary care hospitals in Makkah during the Hajj season.
Methods: This cross-sectional descriptive study included all healthcare professionals working at the ICU departments of two of the largest tertiary care hospitals in the Makkah region during the 1439/2018 Hajj season. The original Maslach Burnout Inventory (MBI) questionnaire was used to measure burnout. Logistic regression models were fitted to estimate the effect size of the associated risk factors.
Results: A total of 354 participants completed the questionnaire. Moderate to severe burnout was found in each of the three subscales: emotional exhaustion, 56%; depersonalization, 82%, and impaired personal achievement, 72%. Nurses were significantly more likely to experience burnout compared with physicians (P = 0.017). Independent predictors of moderate or severe burnout were being aged ≤40 years (odds ratio [OR]: 2.1, 95% CI: 0.395–4.002; P = 0.045), female gender (OR: 2.2, 95% CI: 0.242–4.346; P = 0.037); work having a negative impact on family (OR: 3, 95% CI: 0.164–5.504; P = 0.019); unsatisfaction with salary (OR: 2.8, 95% CI: 0.28–5.056; P = 0.025); and working at the cardiac critical care unit (OR: 2.6, 95% CI: 0.440–4.467; P = 0.035).
Conclusion: This study revealed that the point prevalence of burnout is common among ICU healthcare workers during the Hajj season. These findings can be used by policymakers to devise strategies to mitigate the risks of burnout during the Hajj season.
Keywords: Critical care, Hajj, healthcare workers, intensive care units, Maslach Burnout Inventory, mass gathering, occupational health, professional burnout
The Hajj, the holy pilgrimage to Makkah, is the largest mass gathering in the world with about 2.5 million Muslims attending from >160 countries.[1] This influx of population increases the burden on the healthcare systems due to comorbidities in the population as well as increased prevalence of infectious diseases associated with mass gatherings. For example, in the 2012 Hajj season, pneumonia was reported in 53.9% of the pilgrims and accounted for 27.2% of all intensive care unit (ICU) admissions.[2] During the 2019 Hajj season, the hospitals and healthcare centers in Makkah, Madinah, and the Holy Sites served 649,690 pilgrims, in addition to 6034 inpatients, and conducted 40 open-heart surgeries, 1140 cardiac catheterizations, 3328 dialysis sessions, and 151 endoscopies.[3]
Burnout among health-care professionals in ICUs is common: two recent systematic reviews have shown the prevalence of burnout in this group to range up to 47% and 70.1%, while a study from an Indian tertiary care hospital found the prevalence to be 80%.[4],[5],[6] Some of the factors associated with burnout among ICU healthcare professionals are ethical issues, end-of-life decision-making, the work environment, and work-and shift load.[4],[5] Burnout has potential serious consequences for the healthcare workers and the hospitals, including physical/mental health problems, work–place conflicts, decreased staff performance and quality of patients' care.[7],[8]
During the Hajj season, the healthcare professionals in Makkah city often work 15 successive days to accommodate the high workload, putting them at a risk of burnout. However, to the best of our knowledge, there is only one study that assessed burnout among healthcare professionals in Makkah during the Hajj season, and only included nurses from a single center.[9] Therefore, the current study was conducted with the aim of evaluating the point prevalence and risk factors of professional burnout among all ICU healthcare professionals during the Hajj period at King Abdullah Medical City and Al Noor Specialist Hospital, the two largest hospitals with the highest critical care beds capacity in Makkah.
MethodsStudy design, settings, and participants
This cross-sectional study was conducted between August 15 and 26, 2018, at the time of Hajj (1439 Hijri), and included all healthcare workers in the ICU departments of King Abdullah Medical City and Al Noor Specialist Hospital, Makkah, Saudi Arabia.
The participants included physicians, nurses, pharmacists, and respiratory therapists of medical, surgical, coronary care, and neuro-critical care units.
The study was conducted after obtaining the ethical approval from the Institutional Review Board of King Abdullah Medical City.
Data collection tool and procedure
Data regarding burnout were collected using an English version of the original 22-item, 3-sub-scale Maslach Burnout Inventory (MBI) questionnaire.
The subscales are (a) emotional exhaustion (EE), measured using 9 items to address the feeling of being emotionally drained, (b) depersonalization (DP), measured using 5 items to address the tendency to view the others as objects rather than as feeling persons, and (c) personal achievement (PA), measured using 8 items to address the degree to which a person perceives doing well on worthwhile tasks.[10] A 7-point scoring (0 = never; 6 = every day) was used by the participants to answer each item in the questionnaire. The calculated scores for each domain were categorized as mild, moderate, and sever impairment using the following cut-off values: For EE, mild: 0–16, moderate: 17–26, and severe: ≥27. For DP, mild: 0–6, moderate: 7–12, and severe: ≥13. For low PA, mild: ≥39, moderate: 32–38, and severe: 0–31.
MBI has high reliability and validity, with reliability coefficient of 0.89, 0.74, 0,77 for EE, DP, and PA, respectively.[10] Moreover, the reported Cronbach's alpha of the questionnaire is 0.9, 0.76, 0.76 for EE, DP, and PA, respectively.[9]
A sociodemographic questionnaire was also used to determine potential risk factors associated with burnout. Demographic data collected included age, gender, current designation, and nationality. The social data collected included marital status, number of children, impact of critical care specialty on family life, and satisfaction with salary.
The questionnaire was distributed by the investigators in paper form and in English language only, with the estimated time for questionnaire completion being 6–8 min. The aim of the study and the questionnaire were explained to the participants. In addition, they were informed that participation is voluntary, and were assured of anonymity and data confidentiality. Verbal informed consent was obtained from all participants, and no incentives were offered for participation in the study. The study participants answered the questionnaire independently, and the questionnaire was distributed during the break time of the working shift and re-collected by the investigators at the same shift. Only responses with at least 80% of the questionnaire being completed were considered for the final analysis.
Sample size calculation
A total of 503 participants were eligible for inclusion in the study. Assuming the prevalence of burnout to be 50%, 219 was estimated as the required sample size with a 95% confidence level and 5% error margin.
Data analysis
All obtained data were entered on to a Microsoft Excel (2016) sheet. Statistical analysis was performed using SPSS software version 16 (SPSS Inc., Chicago, IL, USA). Categorical variables were compared using the Chi-square test. Student t-test was used for continuous variables. Logistic regression models were fitted to estimate the effect size of the risk factors by calculating odd ratios (ORs) with 95% confidence intervals. The variables were included in a final multivariate model to obtain adjusted estimates of the ORs and to identify risk factors that were independently associated with burnout. P < 0.05 was considered statistically significant.
ResultsOut of 503 eligible participants, 354 from both hospitals completed the questionnaire (response rate 70.8%); all answered ≥80% of the items in the questionnaire, and thus included in the final analysis. The majority of the participants were aged ≤40 years (318; 90%), male (183; 52%), non-Saudis (272; 77%), married (248; 70%) and had children (209; 59%). The segregation of participants by job is as follows: nurses, 227 (64%); physicians, 60 (17%); respiratory therapists, 63 (18%); and pharmacist 4 (1%). In addition, 230 participants (65%) were from the general ICU, 63 (18%) from the cardiac critical care unit (CCU), 28 (8%) from the cardiac surgery intensive care unit (CSICU), and 33 (9%) from the neuro-ICU [Table 1].
The majority of the participants were satisfied with their income (193; 55%) and perceived their job to have a positive impact on their family (142; 40%) [Table 1].
Burnout and its associated factors
The prevalence of moderate to severe burnout was 56%. The mean ± SD for EE, DP, and PA subscales were 20.3 ± 10.3, 14.2 ± 9.6, and 37.6 ± 9.7, respectively. A total of 198 participants (56%) had moderate or severe EE, 290 (82%) had moderate or severe DP, and 256 (72%) had moderate or severe impairment of PA [Table 2].
Severe or moderate burnout was significantly associated with being aged ≤40 years (65; 20.4%; P = 0.03), female gender (38; 22%; P = 0.02), unsatisfaction with income (105; 65.2%; P = 0.0001), and work having a negative impact on family (23; 39%; P = 0.003). In addition, severe burnout was significantly higher among nurses (24.2%) compared with physicians (18.3%) and respiratory therapists (7.9%) (P = 0.017) [Table 3].
Table 3: Burnout according to the sociodemographic factors and different coverage areasThere was a significant association between type of intensive care unit and severe burnout, with the highest being among those working at the CSICU (32.1%) followed by the general ICU (22.2%), CCU (14.3%), and the least level of burnout was in the neuro-ICU (6.1%) (P = 0.03) [Table 4].
Table 4: Prevalence of burnout based on subscales in different coverage areasLogistic regression analysis
Significant independent predictors of moderate or severe burnout were female gender (odds ratio [OR]: 2.2, 95% CI: 0.242–4.346; P = 0.037); age ≤40 years (OR: 2.1, 95% CI: 0.395–4.002; P = 0.045); job having a negative impact on family (OR: 3, 95% CI: 0.164–5.504; P = 0.019); unsatisfaction with salary (OR: 2.8, 95% CI: 0.28–5.056; P = 0.025) and working at the CCU (OR: 2.6, 95% CI: 0.440–4.467; P = 0.035) [Table 5].
Table 5: Multivariate regression analysis of the risk factors for burnout Discussion This study found that during the Hajj period, there is a considerable prevalence of burnout among ICU healthcare professionals at the two major tertiary care hospitals in Makkah. Our findings are in accordance with those of various studies worldwide that have found that, in general, a significant proportion of ICU healthcare professionals experience burnout.[4],[5],[6],[11],[12],[13],[14],[15] Specifically, a study found that a high proportion of nurses working at the King Abdullah Medical City during the Hajj season experienced burnout.[9] Another study, using different measurement tools, revealed a moderate risk of compassion fatigue/burnout among nurses during the Hajj season.[16] However, no study has evaluated burnout among physicians and other healthcare professionals, except nurses, during the Hajj season for a direct comparison.
Being aged ≤40 years and female gender were significant predictors of professional burnout in our study population. These concur with the findings of several studies, including a landmark study from France that included critical care physicians from 189 ICUs.[5],[11],[15] In a study from Saudi Arabia, age and female gender were also reported to be associated with burnout among physicians across all specialties.[17] Similarly, in the United States, a national survey of physicians found that the prevalence of burnout was higher among females.[14] However, studies from Asia revealed contrasting findings among ICU physicians and nurses: a multinational study of 156 ICUs across 16 Asian countries and region found that age and female gender were not significant predictors of burnout, which were similar to the findings of a nationally representative study from China.[12],[13] The differences across studies may be related to variability across populations in general as well as working pattern differences across countries.
Unsatisfaction with salary and the job having a negative impact on family were also significant independent predictors of burnout in this study. The above-mentioned Asian studies found that salary was not a predictor of burnout, which contrasts our findings.[12],[13] Nonetheless, unsatisfaction would equate to low job satisfaction, which have also been found to be predictors of burnout among ICU physicians and nurses in a Norwegian study and among neonatal ICU nurses in a Canadian study.[18],[19] Working at the CCU was also found to be a predictor of burnout in the current study. The study from China found that burnout was highest among those working at the general ICU.[12] However, these comparisons may not be accurate given that the current study is providing a point prevalence during the Hajj season, where, in addition to the added workload, the turnover of patients at the CCU is more rapid than the other ICU units and is likely to be the contributing factor of burnout.
The Hajj season results in ICU staff in Makkah often working 12-hour shifts for 15 days, leaving them vulnerable to experiencing burnout. In the French survey, the number of in-house duties per month was associated with a higher burnout score.[11] Similarly, a recent study from the United States, in which 45% of the intensivist experienced burnout, found an ebb and flow to burnout, depending on the length of rotation.[20]
Burnout can significantly impact the health and wellbeing of healthcare professionals. For example, ICU physicians and nurses who experience burnout are more prone to symptoms of depression and post-traumatic stress disorder.[21] A bi-directional relationship also exists between burnout and patient safety.[22],[23] Burnout among healthcare professionals can also have an effect on the healthcare system. For example, patient satisfaction with care was found to be directly related to the levels of burnout among nurses.[11] Studies have also found that burnout can result in increased sickness rates and higher attrition rates, both of which increases the work and economic burden on the healthcare systems.[21] Thus, burnout prevention among healthcare professionals should be of a high concern, with an emphasis on building up strategies to alleviate the work stressors, manpower optimization, proper time management, and psychological support of the staff for coping with workload, especially in high seasons of admission such as the Hajj season.
Strengths and limitations
This study has several strength points, including being the first such study to be conducted at the two largest tertiary referral centers in Saudi Arabia and the high response rate providing an adequate representation of the sampled population. Moreover, we studied the prevalence of burnout syndrome in the different coverage areas with different nature of work and patient turnover, unlike the only other study that only focused on a single specialty. However, the study has some limitations, including the generalizability: the workload may differ across different hospitals of Makkah even during the Hajj period, which may contribute to differences in burnout among the healthcare professionals involved in care. Nonetheless, it should be noted that, the two included institutions have settings that are typical for tertiary healthcare facilities in Saudi Arabia.
ConclusionThere was a high prevalence of burnout among critical care healthcare workers at the two major tertiary care hospitals in the Makkah region during the Hajj season. Female gender, younger age group, nonsatisfaction with salary, negative impact of the job on the family, and working at the CCU were found to be the independent predictors of burnout. These findings highlight the need for policymakers to device strategies to mitigate the risks of burnout by optimizing workload coverage during the Hajj season.
Ethical considerations
Ethical approval for the study was obtained from King Abdullah Medical City Institutional Review Board (Reference no.: 18-453) on August 29, 2018. All participants provided a verbal consent for participation. This study followed the general principles of the Declaration of Helsinki, 2013.
Data availability statement
The datasets generated during and/or analyzed during the current study are not publicly available but are available from the corresponding author on reasonable request.
Peer review
This article was peer-reviewed by two independent and anonymous reviewers.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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