Study design
A cross- sectional survey was conducted on physicians in five tertiary health institutions in Nigeria between November and December, 2019 using a pre-tested semi-structured questionnaire.
Ethical approval
The Institutional review board of National Orthopedic Hospital, Enugu gave approval for the study and verbal informed consent to participate in the study was obtained from all the participating physicians.
Sample population and participants
All physicians in all the departments of the enlisted health institutions were eligible for participation in the study. A total population sample of all the physicians in the five tertiary health institutions, located in three states of Nigeria; four in the southern part and one in the northern part of the country was carried out. Owing to their nature as training institutions and other inherent logistic weaknesses it was not possible to obtain the exact number of physicians in any of the centres as entry and exit into the various programs were constantly in a state of flux. In effect, the total number of physicians credited to each institution was the adjudged best estimate from the Association of Resident Doctors (ARD) and Medical and Dental Consultants Association of Nigeria (MDCAN) membership record; these being two broad groups to which all the physicians in the institutions belong. The study questionnaires were in print (paper) format and to minimize response bias they were anonymous and self-administered by the respondents.
Survey administration
The questionnaire titled “A SOCIAL SURVEY OF FEELINGS AND ATTITUDES DURING WORK” comprised of three sections; (i) biodata section of the respondents (ii) a Likert-type scale of respondents rating of the impact of physician burnout on patient safety and (iii) the English version of the 16-item OLBI which is not so labeled. This generic labeling was adopted in an effort to fend off response bias to the tool, which might result if “burnout” were to be expressly mentioned. Each questionnaire is introduced with a definition of burnout thus; Burnout is a psychological syndrome that may result from exposure to a stressful working environment; with high job demands and low resources occurring simultaneously, resulting in exhaustion (general feeling of over-tasking from work) and disengagement (distancing oneself from ones work and negative attitude towards ones work). This is to enable the respondents give informed opinion of how they individually relate burnout to patient safety in the accompanying Likert -type tool. The tool for rating of influence of physician burnout on patient safety is framed thus “Rate your perception of physician burnout as being relevant to patient safety” with the following options; strongly disagree, disagree, undecided, agree, strongly agree.
Survey tool -the OLBI instrument
Oldenburg burnout inventory is a 16-item survey with positively and negatively framed items which measure burnout with two dimensions: exhaustion (physical, cognitive, and affective aspects) and disengagement (negative attitudes toward work objects, work content, or work in general) [2]. In the 16-item version of the instrument used for this study each of these two dimensions is represented by 8 items; with four in each dimension being positively worded and four negatively worded and arranged in a mixed pattern for psychometric balancing. Items 2, 4, 5, 8, 10, 12, 14 and 16 explore exhaustion, while 1, 3, 6, 7, 9, 11, 13 and 15 explore disengagement. Each item has four Likert-type response options which are scored; strongly agree-1, agree-2, disagree-3, strongly disagree-4. Reverse scoring is applied to the items marked with an ‘R’ in the instrument such that strongly agree is scored-4 and strongly disagree-1. In all instances higher scores indicate higher exhaustion and disengagement.
Data collection
The respondents were introduced to the survey during weekly departmental clinical meetings and outpatient clinic sessions. Repeat rounds of visits were made over three weeks by the research assistants to enable the recovery of questionnaires from those who could not complete theirs on the day of the initial distribution and to extend the distribution to those who were not reached previously.
Outcome assessment
The main outcome assessed was burnout as measured by exhaustion and disengagement domain scores of the OLBI tool. Additional outcome measure assessed in the study was the respondents rating of physician burnout as relevant to patient safety; using the 5-item Likert-type template provided in the first section of the questionnaire with options graded as strongly disagree, disagree, undecided, agree, and strongly agree. For the purpose of analysis, the responses in the latter were dichotomized such that the responses of ‘agree’ and ‘strongly agree’ were regarded as YES while the responses of ‘strongly disagree’, ‘disagree’ and ‘undecided’ were regarded as NO with respect to the respondents perception of physician burnout as relevant issue to patient safety.
Data analysis
Data entry and analysis were done using the statistical package for social sciences (SPSS) software version 25 (IBM, Armonk, New York, USA). Continuous variables were summarized using mean and standard deviation while categorical variables were summarized using proportions. For inferential statistics the Student t test was used to compare the difference in mean of two samples, Chi square test was used to compare difference in proportions and ANOVA was used to compare the difference in mean of more than two samples. The level of statistical significance was determined by a p value of < 0.05.
To identify the burnout groups, mean scores ≥2.25 on the exhaustion domain were considered as having high exhaustion, while those who scored less than 2.25 were regarded as having low Exhaustion. For the disengagement domain mean scores ≥2.1 were considered as high while those who scored less than 2.1 were regarded as having low Disengagement. These cut-off scores were adapted from a previous study on burnout among Swedish healthcare workers conducted with the OLBI [5]. The mean score for each domain is obtained by dividing the total scores for the items in the domain by the number of items in the domain; which is eight (8) in each case. The following categories emerged from the respondents;
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Burnout group: high exhaustion and high disengagement
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Exhausted group: high exhaustion and low disengagement
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Disengaged group: high disengagement and low exhaustion
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Non-burnout group: low disengagement and low exhaustion
In order to contend with the unwieldy number of specialties and subspecialties while considering the specialty of the physicians we applied the West African Postgraduate Medical College board classification such that; surgical specialties referred to general surgery, anesthesia, neurosurgery, cardiothoracic surgery, ophthalmology, otorhinolaryngology, pediatric surgery, maxillofacial surgery, orthopedic surgery, plastic surgery, pathology, radiology, obstetrics and gynecology while medical specialties referred to internal medicine, community medicine, psychiatry, family medicine and pediatrics. Medical officers and interns are non-specialists and as such were grouped as ‘Others’.