Introduction disorder in the Diagnostic and Statistical Manual

IntroductionBurnoutis a psychological term for the experience of long-term exhaustion anddiminished interest. Despite this, burnout is not a recognized disorder in theDiagnostic and Statistical Manual of Mental Disorders (1).It was first described in the mid-1970s by Freudenberg and ever since it hasbeen the subject of many studies (2).Burnout focuses on specific stressors in the workplace and the environmentalpressures affecting the health of employed people (3).

Healthcare workers, particularly physicians, are exposed to high levels ofdistress at work. Persistent tension can lead to exhaustion, psychological,and/or physical distress. Moreover, burnout syndrome may increase the risk ofmedical errors and decrease job satisfaction, which incites early retirement (4).

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Burnouthas three interrelated dimensions: emotional exhaustion (EE), depersonalization(DP), and low personal accomplishment (PA). Prolonged exposure to stress isusually the main cause of emotional exhaustion and it manifests through theloss of enthusiasm for work, feeling helpless, trapped, and defeated. Depersonalizationoccurs when physicians treat patients indifferently, objectify them, anddevelop a negative attitude toward their colleagues and profession.

Inefficiency, or the lack of a sense of personal achievement, is characterizedby the individual’s withdrawal from responsibilities and detachment from thejob (5).Thelevel of burnout among physicians varies in different studies conducted indifferent regions of the world. One study conducted described high level ofburnout among physicians by reporting 46% to 80% of physicians with moderate tohigh levels of emotional exhaustion, 22% to 93% of them with moderate to highlevels of depersonalization and 16% to 79% of them with moderate to low levelof personal achievement (6).Burnoutis an increasing problem among medical staff and is highly prevalent inhealth-care settings.

It is associated with difficult working conditions andfeelings of dissatisfaction with work (7).The modern medical workplace is a complex environment, and physicians’responses to it vary greatly. Some find it stimulating and exciting, whereasothers become stressed and burned out from their heavy workload. Severalpersonal, interpersonal and organizational factors have been reported to berelated to job satisfaction, stress and burnout in the medical environment (8-10).Studyfrom developed countries showed that severe burnout syndrome was presented in25% – 70% of physicians (11).

For instance, burnout within a Canadian-based intensive care unit was rangedfrom 36% – 65%, with the highest level of burnout among intensive carephysicians (12).Another study reported that close to half of the intensive care physicianswished to quit their jobs (13).Another study carried in Egypt showed that 39.7% high, 37.7% average and 22.6%low emotional exhaustion; 22.

6% high, 45.6% average and 31.8% lowdepersonalization; 0.8 %  average  and 99.2% low level of personal accomplishment (14).

InAfrican countries, burnout studies are scarce and most have only been developedin the last decade. The debilitation of health systems due to the humanresources crisis has provoked a heavy and complex workload in health care’s andsubstantial workforce burnout. Study conducted in Malawi reported that burnoutlevel among maternal health staff at a referral hospital; 72% emotionalexhaustion, 43% depersonalization and 74% low level of personal accomplishment (15).

Developing countries had a higher burden of disease and fewer healthprofessionals than the developed countries. For example, the ratio of nurses:doctors ranges from nearly 8:1 in the African Region to 1.5:1 in the West (16).In Ethiopia, there were health workforce densities particularly physicians thatshowed 0.

027 per 1000 population (17).Asfar as the researcher investigated, there is no similar study conducted inEthiopia on burnout level and its associated factors among physicians. Inaddition, Ethiopian physician number is not comparable with patient volume sothat the physicians in the work become over stressed. This was evidenced thatthe number of physicians in Ethiopia was estimated to be 1 544.

This implies aphysician to population ratio of 1:42 706 in Ethiopia and 1: 74161 in SNNPRS but the World Health Organization (WHO) minimum standard was 1:10000 (18).Thus, this study designed to address the problems by assessing the burnoutlevel and its associated factors among physicians in public hospitals ofSouthern Nations, Nationalities and Peoples’ Regional State (SNNPRS) in whichcase the findings of  this  study will help  health  care institutions; particularly hospitals to recognize  factors related to  burnout in medicalstaff  and help  them to take corrective measures  in attempt  to improve the healthstatus of their employees.Methods and MaterialsStudy Setting andSampling This study was carried out fromMarch 13 to April 11, 2017 in all primary, general and specialized publichospitals of SNNPRS. Administratively the Region is divided into 14 zones, 1City Administration zone and 4 special woredas. According to Central StatisticalAgency (CSA) 2007 census, the regional total population was 14929548 ( male49.7% and female 50.3%) (2).

Currently there are 40 (8 generaland 32 primary) hospitals reporting to health bureau of the region and 6specialized/teaching hospitals in the region (3).Institutional basedcross sectional study design was employed to investigate burnout amongphysicians in public hospitals of Southern Nations, Nationalities and Peoples’Regional State (SNNPRS), Ethiopia and all physicians (491) who were working inall public hospitals of the region during data collection period were includedin the study.   Data collection and measurementsStructuredquestionnaires were adopted from English version  of Maslach’s  Burnout  Inventory-Human  Services Survey  (MBI-HSS)  to collect data on levels  of burnout among physicians. It comprised of  22 items  regrouped  into 3  subscales:  emotional exhaustion  (EE;  nine items), depersonalization (DP; five items), and personal accomplishment(PA; eight items). Each item was answered on a 7-point likert scale rangingfrom “never” (=0) to “daily” (=6).

Each aspect of the burnout syndrome wasmeasured and scored separately. Thus a  high  score on  emotional  exhaustion and  depersonalization,  and a  low  score  on  personal accomplishment was reflected as ahigh level of burnout. A low level of burnout was considered as equivalent to alow score on emotional exhaustion and depersonalization, and a high score onpersonal accomplishment (19).Instruments were prepared in English language. Participants were  asked to provide information  with regard  to  their age, sex, marital status, educational level, area of work and years ofexperience, duty hours, recognition from others regarding work, professionaltraining, smoking, chat chew,  workoverload,  monthly income, conflict withcolleagues, and  intention  to leave  work  within next six months.Data AnalysisDatawas checked manually for completeness and consistency. Collected data werecompiled, cleaned, coded and entered into Epi Data version 3.1software and SPSS version 21 was used for statistical data analysis.

Errors, missing values and outlierswere checked and treated accordingly. Factor analysis based on principalcomponent extraction followed by varimax rotation was used within the adopted22-item scale. Three factors were obtained, with eigenvalues of 4.

94, 3.02, and2.46. The total variance explained was 50.0%.

The three factors identified, inorder of percentage variance explained, represented by emotional exhaustiondimension (23.6%), depersonalization (14.4%), and personal accomplishment (12%)and the final scale consisted of 21 items.

Internal consistency of themeasurement scale was investigated through Cronbach’s alpha coefficient and was found to be 0.720 for emotional exhaustion, 0.846 for depersonalizationdimension and 0.

701 for personal accomplishment. Presence of statisticalassociation between independent and dependent variables was observed bybivariate analysis and candidate variables with P-value < 0.25 was includedinto multiple linear regression analysis. Multivariate linearregression analysis was done through enter method to identify the mostsignificant predictors. Assumptions in multiple linear regressions (linearity,normality, and constant variance) were checked. Significant independentpredictors were declared at 95% confidence interval and P-value of less than0.05 and unstandardized? was used for interpretation. Result Fourhundred ninety one participants were involved in the study with 100 % responserate.

More than two third (70.9% & 67.6%) of study participants were maleand single respectively. Majority (86.6%) of the respondents were generalpractitioners (Table 1).

Asto work related characteristics of the respondents, close to one third142(28.9%) and half, 215(43.8%) were working in medical department andspecialized/teaching hospitals respectively. The mean professional workexperience and mean working hours per month was found to be 1.92 years and120.65 hours respectively. Regarding interpersonal conflict about half (48.

7%)of study participants experienced conflict with their colleagues (Table 2).Regardingburnout level of study participants, 320(65.2%) scored high degree of emotionalexhaustion, 418(85.1%) scored high degree of personalization and 447(91%)experienced low levels of personal accomplishment (Table 3). BivariateLinear Regression Analysis Bivariate analysis was conducted to identifycandidate variables for multiple linear regression analysis at p < 0.25.

Accordingly age (p-value = 0.001), monthly salary (p= 0.229), number ofpatients observed per week (p=0.001), sleeping hours in working day (p=0.

108),average working hours per week (p=0.003), having any support from family and ororganization (p=0.002), professional training (p=0.011) and receivingrecognition from others regarding work (p=0.009) were found to be candidatesvariable.

MultiVariable Linear Regression Analysis Inthe multivariate model, receiving recognition from others regarding work (? = -0.05, 95%CI = -0.09, -0.

01), monthly salary (? = -0.01, 95%CI= 0.01-0.02) and age (? = -0.01,95%CI: -0.01, -0.01) were negatively associated with emotional exhaustion score. Whereas number of patients observed per week (?= 0.

01, 95%CI= 0.001, 0.01) was positively associated with emotional exhaustion score.Multicollinearity was checked and the variance inflation factor (VIF) for allvariables found to be < 10 and the tolerance > 0.2 (Table 4). DiscussionThepresent study aimed to assess burnout level and to identify some associatedfactors that trigger burnout among physicians. In this study the respondentswere experienced high burnout by reflecting high emotional exhaustion 65.

2%(95%CI= 61.1, 69.7), high depersonalization 85.1% (95%CI= 81.7, 87.9) and lowpersonal accomplishment 91% (95%CI= 88.

6, 93.3). Similar study carried out inRiyadh reported high burnout with 53.5% of respondents scored high foremotional exhaustion, 38.9% for depersonalization and 28.

5% low for personalaccomplishment (20).Another similar study conducted by Sami Al-Dubai in Yemen showed that highburnout levels by reflecting 63.2% emotional exhaustion, 19.4% highdepersonalization and 33.0% low personal accomplishment among physicians (21).

The current study finding showed higher level of burnout. Possible explanationfor this difference might be variation in culture and poor employmentcondition.Anotherstudy carried out in Egypt showed that 39.7% high emotional exhaustion; 22.6%high depersonalization and 99.2% low level of personal accomplishment (14).Our results for both emotional exhaustion and depersonalization are higher butlower for low level of personal accomplishment. Probable reason for higherfinding was over stressed at work and less human resources but for lower casecompetition among the professionals might be higher to achieve the work.

Ingeneral probable reason for the difference in the prevalence of burnoutsyndrome across different countries can possibly be explained by variations inculture, the nature of the health system (including structural and servicedelivery problems in different countries) and the role of physicians ashealth-care providers. Inthis study burnout level as measured by the three dimensions were predicted byage, monthly salary, hospital type, receiving recognition from others regardingwork, professional training and having support from family and or organization.This findings noted that being hospitals type of primary (?= -0.07, P-V<0.001) was negatively associated with depersonalization dimension ofburnout level. On the other hand study done in shanghai showed that hospitaltype of primary (?= 0.17; p<0.05) was positively associated withdepersonalization dimension of burnout (22).

The possible differences for this finding was the level of primary careservices might be better in our country as compared to shanghai.  Inthis study average numbers of patients examined per week (?= 0.001; p<0.001)was positively associated with emotional exhaustion dimension of burnout level.Similar study done in a Province in Eastern Anatolia also identified averagenumber of patients examined per week (?= 2.

64; p<0.05) was positivelyassociated with emotional exhaustion dimension of burnout level (23).Another study carried out in Turkey showed that number of patients examined waspositively associated with emotional exhaustion dimension of burnout level (24).Incurrent study age was negatively associated with emotional exhaustion (?=-0.007; p<0.001)   anddepersonalization (?= -0.011; p<0.

001) dimensions of burnout. In anothercontext as age increase, emotional exhaustion and depersonalization decreasesby controlling other variables. A possible reason is that younger physiciansare less experienced and they may become more cognitively overwhelmed with theworkload of a routine work day. But the study conducted in Turkey showed thatage was not significant predictor for emotional exhaustion anddepersonalization dimensions of burnout and positively associated for onlypersonal accomplishment dimension of burnout (25).The study conducted in Shanghaishowed that average working hours per week (?= 0.

1; p<0.5) was positivelyassociated with emotional exhaustion dimension of burnout (22)but in our finding working hours per week was not significant predictors ofemotional exhaustion dimensions of burnout. The probable reason for this mightbe high work overload in Shanghai compared to our country. Conclusionand recommendationBurnout was measured in threedimensions and it was found in a high level among physicians currently workingin public hospitals of South Nations Nationalities and Peoples region.Receiving recognition from others, age,working in primary hospital, monthly salary having any support from family andorganization, and gettingprofessional training can possibly minimize the level of burnout amongphysicians in the region.

On the contrary, increase in the number ofpatients observed per week increases burnout. All the concerned bodies shouldwork collaboratively to decrease the risk of burnout by addressing thecontributing factors identified by this study.