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ORIGINAL ARTICLE |
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| Ahead of print
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| Burnout and resilience among resident doctors working at a COVID-19 nodal center in India |
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Varsha Sriperambudoori1, Srilakshmi Pingali2, Umashankar Molanguri3, T Deekshith4, Ajay Kumar Joopaka5
1 Senior Resident, National Drug Dependence Treatment Centre (NDDTC), Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
2 Professor & HOD, Department of Psychiatry, Government Medical College, Sangareddy, Telangana, India
3 Professor and HOD, Department of Psychiatry, Gandhi Medical College, Secunderabad, Telangana, India
4 Junior Resident, Department of Psychiatry, Gandhi Medical College, Secunderabad, Telangana, India
5 Associate Professor, Department of Psychiatry, Gandhi Medical College, Secunderabad, Telangana, India
Click here for correspondence address and email
| Date of Submission | 11-Sep-2022 |
| Date of Acceptance | 18-Nov-2022 |
| Date of Web Publication | 28-Feb-2023 |
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Background: COVID-19 pandemic can lead to burnout among health workers. The study aimed to know the prevalence of burnout among resident doctors and its relation to resilience.
Methodology: An online anonymous cross-sectional study was done at the sole COVID nodal center of Telangana, India, using a three-part questionnaire E-mailed to all the resident doctors. It included a consent form, sociodemographic data, the Copenhagen Burnout Inventory to measure burnout, and the Brief Resilience Coping Scale to measure resilience. Data were analyzed using SPSS statistical software version 22.0 (IBM). P value was considered statistically significant below 0.05 and all tests were two-tailed.
Results: Personal burnout (53.6%) was highest followed by work-related burnout (46.4%) and client-related burnout (40.8%). All three domains of burnout showed a significant negative correlation with scores of resilience (personal burnout [r = −0.240), work burnout (r = −0.203), and client burnout [r = −0.212]; P ≤ 0.001).
Conclusion: Client-related burnout has increased when compared to nonpandemic times. Burnout was inversely associated with resilience, suggesting a role for resilience as a protective factor.
Keywords: Burnout, COVID-19, resident doctors, resilience
How to cite this URL:
Sriperambudoori V, Pingali S, Molanguri U, Deekshith T, Joopaka AK. Burnout and resilience among resident doctors working at a COVID-19 nodal center in India. Arch Ment Health [Epub ahead of print] [cited 2023 Mar 24]. Available from: https://www.amhonline.org/preprintarticle.asp?id=370757 |
| Introduction | |  |
Health-care workers are working tirelessly to keep up with the massive health-care demands during the COVID-19 pandemic. This has led to negative psychological effects on the health-care workers and their families.[1],[2] One such effect is burnout, which is increasingly being recognized as a major concern. Burnout is defined in the International Classification of Diseases 11 as “A syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed. It is characterized by three dimensions: feelings of energy depletion or exhaustion; increased mental distance from one's job, or feelings of negativism or cynicism related to one's job; and reduced professional efficacy.”[3] One of the factors that buffer against burnout is resilience. Resilience in simple terms is the ability to bounce back from adversities and the ability to cope with stress in a highly adaptive manner.[4] It has three core components: plasticity, sociality, and meaning. It includes flexible adaptation to adversities, maturation of stress management system, and giving meaningful significance to human suffering.[5],[6]
Most of the studies on burnout are from high-income countries.[7],[8],[9],[10]
The purpose of this study is to know the prevalence of burnout among resident doctors and its relation to resilience. To our knowledge, prior to the initiation of this study, there were few to none studies to assess the relation between resilience and burnout among doctors during COVID-19 pandemic in India. This may contribute to literature on burnout in low- and middle-income countries and serve as an evidence to develop strategies to build resilience and combat burnout.
| Methodology | | |
The study was a cross-sectional survey of all resident doctors posted in the hospital. It has been approved by the institutional ethics committee. The Checklist for Reporting Results of Internet E-Surveys (CHERRIES) was used to plan this study to improve the quality.[11] Contacts of all concerned doctors were obtained from the hospital administration after due permission, and a three-part questionnaire was E-mailed to them. The first part was a semi-structured questionnaire designed to capture the sociodemographic data. The second part was the Copenhagen Burnout Inventory (CBI) to assess for burnout,[12] and the third part was the Brief Resilience Coping Scale to assess resilience.[13] The questionnaire also included a consent form and took about 10 min to complete. It was an anonymous survey for voluntary participation. No monetary incentives were offered. Participants were provided a contact for psychiatric assistance. The number of responses was restricted to one per person to avoid duplication of data. Participants could review or change their responses before submission.
Study size
Taking the prevalence of burnout in health-care workers to be 50% as shown by previous studies, 95% confidence interval, 5% margin of error, and 10% nonresponse rate, a total of at least 260 samples were arrived at.[14] A total of 267 completed responses were recorded. The data so obtained were analyzed.
Tools used
Sociodemographic data
It included questions related to age, gender, education, occupation, number of working hours, whether they have tested COVID positive since the time of the pandemic, past and family history of psychiatric illness, and willingness to seek mental health help.
Copenhagen Burnout Inventory
The CBI has 19 items with three subscales: personal (six items), work burnout (seven items), and client burnout (six items). Twelve items have responses of frequency along a five-point Likert scale ranging from “100 (always)” to “0 (never/almost never).”[12] Seven items use responses of intensity ranging from “a very low degree” to “to a very high degree.” For example, usual items are: “how often do you feel tired” and “do you find it hard to work with clients.” A score of 50 or more denotes that burnout is present. Scores ranging from 50 to 74 are considered “moderate,” 75–99 high, and a score of 100 is considered to be severe burnout. It is a standardized and validated instrument with consistently strong psychometric properties. It has been studied and applied in resident doctors and physicians.[15]
Brief Resilience Coping Scale
The Brief Resilient Coping Scale (BRCS) is a 4-item standardized and validated instrument to measure tendencies to cope with stress in a highly adaptive manner.[13] The BRCS has adequate internal consistency (r = 0.76) and test–retest reliability (r = 0.71). So far, the BRCS has been studied and applied across samples, such as medical students, nursing students, and doctors.[16]
Data analysis
Data obtained were analyzed using IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp. P value was considered statistically significant below 0.05, and all tests were two-tailed. As the scores of burnout and resilience followed a nonnormal distribution, the values were represented as medians with interquartile range. Nonparametric tests such as MannWhitney U-test and KruskalWallis tests were applied to compare burnout among two or more groups. Spearman's rho was used to correlate scores of burnout and resilience. Binominal logistic regression was done to see the association of the absence or presence of burnout in three subscales with categories of resilience.
| Results | | |
The mean age of participants was 25.04 (±2.67) years (age range: 21–43 years). Most of the respondents in the study were females (65.2%), unmarried (89.1%), interns (50.2%), living with family (54.7%), were involved in direct care of patients with COVID-19 (97.8%), intensive care unit (ICU) workers (57.3%), and working for more than 48 h per week (56.6%). Among the respondents, 4.5% had past history of mental illness and 7.1% had family history of mental illness. Medium-resilient copers (47.2%) made up the highest proportion followed by low- (39.7%) and high-resilient copers (13.1%). The detailed sociodemographic profile of the population is given in [Table 1].
The prevalence of personal burnout (53.6%) was highest followed by work-related burnout (46.4%) and client-related burnout (40.8%) [Table 2].
Those who worked for longer and mainly in ICU showed significantly higher rates of burnouts in all three subscales. The mean scores of burnout across three subscales were as follows: personal (299.06), work related (323.97), and client related (235.67). The mean score of resilience was 13.89. The scores of burnout and resilience are represented as median with interquartile range, as given in [Table 3] and [Table 4]. | Table 3: The scores of burnout and resilience are represented as median with interquartile range
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 | Table 4: Burnout scores across various categories represented as median with interquartile range
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Those who mainly worked in ICU and had >48 working hours per week showed significantly higher burnout rates on all three subscales of CBI. Females, interns, and those with past history of mental illness showed significantly higher scores of personal burnout (females 325 [225–375] vs. males 275 [200–375], P < 0.01; interns 300 [250–375] vs. postgraduate trainees 275 [200–375], P < 0.01; with past history of mental illness 437 [306–468] vs. without past history 300 [225–375], P < 0.01). Those with past history of mental illness had significantly higher work-related burnout (with past history of mental illness 450 [243–500] vs. without past history 325 [225–425], P = 0.03).
The distribution of all three domains of burnout varied significantly across different categories of resilience with low-resilient copers showing the highest burnout followed by medium-resilient copers and high-resilient copers. All three domains of burnout showed a significant negative correlation with scores of resilience (personal burnout [r = −0.240]; work burnout [r = −0.203]; client burnout [r = −0.212]; P < 0.01 for all of them), as shown in [Table 5]. | Table 5: All three subscales of burnout showed a significant negative correlation with scores of resilience Personal burnout (r=-0.240); work burnout (r=-0.203); client burnout (r=-0.212); P<0.001 for all of them
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Low-resilient copers had significantly higher odds or likelihood of having burnout when compared to medium- and high-resilient copers. The odds ratio with confidence interval of 95% with P < 0.05 [Table 6]. | Table 6: Binominal logistic regression was done to see the association of absence or presence of burnout in three subscales with categories of resilience
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No other sociodemographic factors were associated with burnout in any three subscales of CBI.
| Discussion | | |
In March 2020, a tertiary care health center located in Secunderabad, India, was designated as the sole COVID-19 center for the state of Telangana having more than 30 million population. It soon emerged as an epicenter for COVID-19 admissions. The rapid rise in cases in excess of resources available at a single hospital led to an unprecedented situation among the frontline workers. Hence, we chose to assess burnout among resident doctors who were the most likely to involve in the direct care of patients.
Studies done during previous pandemics reported high distress levels in frontline health workers, particularly doctors and nursing staff.[17],[18],[19] The higher prevalence of psychological problems was reported in medical health workers when compared to nonmedical health workers.[20],[21] Sources of concern included infection to self and others, lack of PPE, long working hours, massive health-care demands to name a few.[22],[23] Academic pressure, job dissatisfaction, long working hours, competing family interests, and interpersonal conflicts at work are some of the factors that contribute to burnout.[24] The massive health-care demand, fear of infection to self and others, uncertainty, resource shortage, and disruption of work–life routine might act as an aggravation contributing to burnout.[25],[26],[27]
Burnout has a variable incidence in literature ranging from 18% to 82%.[9],[22],[27] A global survey of HCWs from 60 countries reported a 51% burnout prevalence during the COVID-19 pandemic.[28] In an Indian survey, the prevalence of personal burnout was 44.6%, work related 26.9%, and >50% had pandemic-related burnout.[22]
We found it more appropriate to use the CBI to study burnout in the current pandemic scenario. It includes both positive and negative phrases, covering physical and cognitive aspects of exhaustion across three independent domains reflecting different aspects of HCWs' activities, with more discriminatory power. Our results showed that the mean score of work-related burnout in the HCWs was significantly higher than that of the personal- and client-related mean scores. However, when the prevalence was considered, the prevalence of personal burnout was highest followed by work and client related. The increasing work demands during the pandemic along with the increasing emotional demands and demands on the home front, possibly lead to a skewed work–life balance and led to increased burnout.[29],[30],[31]
Studies done during nonpandemic times using CBI reported higher rates of personal- and work-related burnouts than client-related burnout.[32],[33],[34] Our study had similar findings. However, the client (patients)-related burnout in our study was higher when compared to those during the pre-COVID-19 era (40.8% vs. 16.67%).[35] This may be due to gradual increase in number of COVID-19 cases with most of them requiring hospitalization. The client-related burnout in our study is lower than reported in other studies done during the pandemic.[22] This may be accounted for by the protection conferred by resilience.
Working in emergencies and critical care were found to be significantly associated with burnout in all three subscales. This is in line with previous studies reporting the highest levels of burnout in health workers working in emergencies.[10],[36] Previous studies have shown that residents rated interpersonal relationship conflicts, work hours, less autonomy, time, and work planning as stressful work characteristics.[37]
Previous studies report long working hours to have a significant association with burnout.[38],[39],[40] Longer working hours led to greater stress and exhaustion with poorer perception of learning environment and active avoidance coping.[41] This is in accordance with our findings, where long working hours (longer than 48 h in a week) were significantly associated with burnout.
Females were found to have higher burnout than males in this study, which is in line with the findings of previous studies.[9],[40],[41] An Indian survey done during the pandemic reported that females had higher personal burnout.[22] This might be explained by their dual role in the society and multiple responsibilities both at home and workplace.
Interns were found to have higher burnout than postgraduate trainees in our study. Previous studies reported that less experienced and early-career physicians are at a higher risk of burnout.[42],[43] Those with less experience might find it difficult to effectively navigate the demands of their profession which may contribute to increased perception of burnout.
Past history of mental illness was significantly associated with the presence of personal and work burnout in our study. Those with past history of psychiatric illness have higher chances for developing subsequent episodes and further deterioration.[14],[44],[45]
The prevalence of burnout reported in studies during the pandemic varied considerably.[9],[22],[28] These differences may be due to the use of different measuring tools or modified versions of the same. Our findings suggest that local factors (social, cultural, health system, and collective stressor dealing) may influence levels of stress, resilience, and mental health. Resilience may be acting as a protective factor in preventing burnout.
In our study, resilience was inversely associated with burnout. Studies done during COVID pandemic reported higher burnout to be associated significantly with lower resilience scores.[8],[9],[41],[46] Resilience has a buffering effect on burnout and plays a protective role in its regulation and prevention.[47]
Burnout was present even in high-resilient copers. Our findings imply that additional solutions are required to address issues related to all three domains (personal, work, and client related) of burnout. Among individual-focused approaches, mindfulness with resilience training was shown to reduce burnout and improve overall well-being.[48],[49],[50]
In a survey done during COVID-19 pandemic, most participants expressed that they would like the expansion of mental health services in near future.[44] The consequences of pandemic are severe and hence it is important to identify protective factors that may help people to cope in the face of future outbreaks.
Strengths
Prior to the initiation of this study, to our knowledge, no Indian studies were found on burnout and its relation to resilience during the COVID-19 pandemic. It adds to literature on burnout in low-resource settings such as India. It brings about awareness about burnout and the need to address it. Three different domains of burnout were represented. A checklist for web-based surveys (CHERRIES) was used to plan this study. It includes resident doctors who are much more likely to be working closely with patients during the pandemic.
Limitations
This was a single-center cross-sectional study; therefore, the temporality of association could not be established and the findings may not be generalized to other regions. No control group was used. Convenience sampling was used. No longitudinal follow-up was done, and an online anonymous study may result in self-reporting bias.
| Conclusion | | |
A considerable proportion of respondents reported burnout in this study. Client-related burnout has increased when compared to pre-COVID era studies done in the recent past. Burnout was inversely associated with resilience, suggesting a role for resilience as a protective factor. Burnout was present even in high-resilient copers. It serves as an evidence to address the psychological adversities afflicting front-line workers and workplace burden. There is a need for further assessment of protective and detrimental factors involved in burnout, especially in low-resource settings such as India.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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Correspondence Address:
Srilakshmi Pingali,
Department of Psychiatry, Government Medical College, Sangareddy - 500 003, Telangana
India
 Source of Support: None, Conflict of Interest: None DOI: 10.4103/amh.amh_140_22
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6] |
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