Physician Burnout and Patient Care Practices in Sierra Leone

doi:10.21203/rs.3.rs-4708983/v1

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Physician Burnout and Patient Care Practices in Sierra Leone

https://doi.org/10.21203/rs.3.rs-4708983/v1

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Background

Burnout, characterized by emotional exhaustion, depersonalization, and reduced personal accomplishment, can negatively impact patient care. While burnout is well-studied in developed nations, research in resource-constrained settings like Sierra Leone remains limited. This study aimed to quantify burnout prevalence among Sierra Leone's public sector physicians and its impact on self-reported patient care practices.

Methods

The study involved a random sample of physicians from major government hospitals across Sierra Leone's administrative regions. Burnout was assessed using the Maslach Burnout Inventory (MBI), and self-reported patient care practices were evaluated using an adapted version of Shanafelt et al.'s 2002 questionnaire. Statistical analyses included chi-square tests, Fisher exact tests, and logistic regression to explore associations between burnout, demographic variables, and patient care practices.

Results

A total of 140 physicians (31% female, 69% male, p = 0.8), 51.4% met burnout criteria. Burnout was similar across genders (p = 0.8) and age groups (p = 0.5). Most respondents were aged 26–35. Marital status did not differ significantly (p = 0.8), with 54% single overall. Regional distribution showed no significant difference (p = 0.5), with 78% from Western Urban. Duration of practice was also similar (p = 0.5), with 35% house officers, 39% medical officers, and 26% senior medical officers. Physicians experiencing burnout were more likely to report high emotional exhaustion (62%), high depersonalization (44%), and low personal accomplishment (46%). Burnout was also associated with suboptimal patient care practices, including avoiding diagnostic tests due to cost concerns, expediting patient discharge, and prescribing medication without proper evaluation.

Conclusion

This study revealed a high prevalence of physician burnout in Sierra Leone, which significantly impacts patient care and physician well-being. A multipronged, collaborative approach is necessary to address burnout, involving individual, organizational, and systemic interventions. Further longitudinal research is needed to develop contextually relevant strategies to support healthcare workers in resource-constrained settings.

Burnout

Prevalence

Sierra Leone

Physicians

Sierra Leone, a West African nation with about 7.7 million people, has faced significant challenges in its healthcare sector, particularly in the aftermath of an eleven-year civil war and the catastrophic Ebola outbreak in 2014 (1, 2). These events have exacerbated the country's already fragile healthcare infrastructure and delivery systems, resulting in a critical shortage of healthcare workers primarily concentrated in urban areas (3). Consequently, the demand for a limited number of healthcare providers in the public sector is dire, potentially contributing to an increased risk of burnout among these professionals.

Burnout is a syndrome of depersonalization, emotional exhaustion, and a sense of low personal accomplishment which can result in substantial impact on work efficiency, attrition rate, decreased turnovers, and patient care (4). Unlike depression, burnout primarily focuses on an individual’s relationship to their work and it impacts on the recipients of the services (5).

While burnout has been extensively studied in the developed world, (5–9) research in developing countries (10, 11), particularly in regions like Sierra Leone, remains scarce. This gap in literature highlights a need for studies focused on understanding burnout among physicians in such contexts, where the challenges are unique and often more severe due to limited resources, high patient-to-doctor ratios, infrastructural challenges, and a lack of autonomy. Furthermore, external stressors such as infectious disease outbreaks can exacerbate these challenges, as evidenced by the global healthcare community's experience during the COVID-19 pandemic (10).

This study quantified the prevalence of burnout among public sector physicians in Sierra Leone, examining its impact on self-reported patient care practices. By understanding the extent of burnout within Sierra Leone's public healthcare system, this research generates evidence to guide strategic resource allocation. Such targeted interventions could support physician well-being, optimize their performance, and ultimately enhance the quality of patient care within this resource-constrained environment.

Study design and population

This was a cross-sectional study conducted across major government hospitals in Sierra Leone between April 2022 and July 2022.

The target population was all public-sector physicians in Sierra Leone. The source population were accessed at each of the major government hospitals spanning the five administrative regions in Sierra Leone (Northern, Northwestern, Southern, Eastern and Western area).

Data collection, recruitment and outcomes

The data collection process utilized a paper-based, self-administered questionnaire (Supplement #1). Additionally, the survey was made available online via a secure server through Microsoft Forms to accommodate physicians who might not have had the time to complete the paper-based version. The survey was distributed through email, phone, or personal office visits to maximize the response rate.

The primary outcome was burnout and the proportion of suboptimal patient care practices and attitudes among physicians in the public sector. Burnout prevalence was quantified as the number of physicians meeting the established criteria for burnout to the total number of questionnaire respondents. Similarly, the proportions of unfavourable patient care practices and attitudes were calculated using a similar approach.

Burnout was assessed using the Maslach Burnout Inventory (MBI) (4), a validated 22-item questionnaire considered the gold standard for burnout measurement. Participants responded on a 7-point Likert scale indicating the frequency of work-related feelings. The MBI measures burnout across three domains:

Emotional Exhaustion (9 items): Emotional depletion due to work (e.g., "I feel emotionally drained from my work").
Depersonalization (5 items): Detachment and cynicism towards patients or clients (e.g., "I've become more callous toward people since I took this job").
Personal Accomplishment (8 items): Diminished feelings of competence and achievement at work (e.g., "I feel I'm positively influencing people's lives through my work").

Subscale scores were calculated and categorized as low, intermediate, or high for each domain.

Similarly, we adapted the Shanafelt et al 2002 Providers Self-Reported Patient Care Practices and Attitudes Questionnaire (5) (see Supplement #2) to assess the impact of burnout on patient care. This questionnaire measures self-reported suboptimal care practices and associated attitudes. Respondents were asked to indicate how frequently they exhibited specific attitudes or behaviors, potentially influenced by factors like time constraints or feeling rushed. The response scale included the following options: Never, Once, Several times per year, Monthly, and Weekly.

Statistical Analysis

Burnout was defined as poor scores on at least two of the three MBI subscales (i.e., high, intermediate, and low: emotional exhaustion, depersonalization, and personal accomplishment). To compare the proportion of physicians meeting the criteria for burnout across age, sex, marital status, duration of practice, and region of practice, a bivariate analysis was conducted. The chi-square test or Fisher’s exact test was used, depending on the distribution of the comparison groups, to determine statistical significance. Logistic regression was used to evaluate whether burnout was independently associated with self-reported suboptimal patient care practices and attitudes (reported weekly versus monthly or less). This analysis was controlled for age, sex, marital status, duration of practice, and region of practice. As a secondary outcome analysis, each MBI subscale (emotional exhaustion, depersonalization, and personal accomplishment) was evaluated as an independent variable using a multinomial logistic regression. All analyses were conducted at an alpha level of 0.05.

Sample size and power

The maximum sample size was predetermined at 150 participants. Assuming an odds ratio of 2.5 and a 30% prevalence of physicians exhibiting suboptimal monthly patient care practices and attitudes, the study was designed to achieve a statistical power of 97%. However, accounting for a hypothesized response rate of 85%, which is likely a conservative estimate, the effective sample size would be reduced to 130 participants, yielding a power of approximately 95%. Additionally, detecting a 20% difference in burnout prevalence between groups required a total sample size of 130 participants (comprising both senior and junior physicians) to attain 90% statistical power. Nonetheless, given the exploratory nature of the study design and the convenience sampling approach employed for recruitment, considerations of statistical power were of lesser importance in this study.

Participant Demographics

In this cross-sectional study, 140 individuals completed the survey, comprising 43 females (31%) and 96 males (69%) (p = 0.8). Of the total participants, 72 (51.4%) met the burnout criteria. The distribution of burnout did not significantly differ by sex, with 29% of non-burnout physicians and 32% of burnout physicians being female (p = 0.8).

The age distribution was also similar between the two groups (p = 0.5). Most respondents were aged 26–30 (38%) and 31–35 (40%). In the burnout group, 36% were aged 26–30 and 44% were aged 31–35, while in the non-burnout group, 40% were aged 26–30 and 35% were aged 31–35.

Marital status was not significantly different between groups (p = 0.8). Overall, 54% of the respondents were single at the time of the survey. In the burnout group, 50% were single and 43% were married, compared with 57% single and 40% married in the non-burnout group.

The demographic characteristics, response rates, and unadjusted MBI-HSS(MP) scores of each cohort are presented in Table 1.

Table 1

Descriptive analysis for Burnout versus No Burnout in Physicians across Sierra Leone in 2022.
Characteristic	Overall, N (%) = 140¹	No Burnout, N = 68¹ (%)	Burnout, N = 72^{1 (%)}	p-value²
Sex				0.8
Female	43 (31.0)	20 (29.0)	23 (32.0)
Male	96 (69.0)	48 (71.0)	48 (67.0)
NA	1 (0.7)	0 (0.0)	1 (1.4)
Age, range (years)				0.5
20–25	2 (1.4)	1 (1.5)	1 (1.4)
26–30	53 (38.0)	27 (40.0)	26 (36.0)
31–35	56 (40.0)	24 (35.0)	32 (44.0)
36–40	21 (15.0)	13 (19.0)	8 (11.0)
41–45	5 (3.6)	2 (2.9)	3 (4.2)
51–55	2 (1.4)	0 (0.0)	2 (2.8)
61+	1 (0.7)	1 (1.5)	0 (0.0)
Marital Status				0.8
Single	75 (54.0)	39 (57.0)	36 (50.0)
Married	58 (41.0)	27 (40.0)	31 (43.0)
Divorced	4 (2.9)	1 (1.5)	3 (4.2)
Separated	1 (0.7)	0 (0.0)	1 (1.4)
Prefer not to answer	2 (1.4)	1 (1.5)	1 (1.4)
Duration of practice (years)				0.5
< 2 years	45 (35.0)	23 (38.0)	22 (33.0)
2–5 years	50 (39.0)	25 (41.0)	25 (37.0)
> 5 years	33 (26.0)	13 (21.0)	20 (30.0)
NA	12	7	5
Region of practice				0.5
Western Urban	109 (78.0)	55 (81.0)	54 (75.0)
Western Rural	9 (6.4)	2 (2.9)	7 (9.7)
Southern	4 (2.9)	1 (1.5)	3 (4.2)
Northern	4 (2.9)	3 (4.4)	1 (1.4)
North-West	5 (3.6)	3 (4.4)	2 (2.8)
Eastern	8 (5.7)	3 (4.4)	5 (6.9)
Physical activity for at least 15 minutes per week				0.2
0 days	8 (5.7)	3 (4.4)	5 (6.9)
1–2 days	75 (54)	32 (47.0)	43 (60.0)
3–4 days	34 (24)	19 (28.0)	15 (21.0)
5–7 days	22 (16)	14 (21.0)	8 (11.0)
NA	1 (0.7)	0 (0.0)	1 (1.4)
Sleep per night (hours)				0.054
≤ 5	61 (44)	25 (37.0)	36 (50.0)
6	49 (35)	25 (37.0)	24 (33.0)
7	18 (13)	8 (12)	10 (14.0)
8	9 (6.5)	8 (12)	1 (1.4)
9	1 (0.7)	1 (1.5)	0 (0.0)
NA	1 (0.7)	0 (0.0)	1 (1.4)
Overall health				0.3
Very Good	38 (27.0)	19 (28.0)	19 (26.0)
Good	82 (59.0)	43 (63.0)	39 (54.0)
Fair	18 (13.0)	5 (7.4)	13 (18.0)
Poor	2 (1.4)	1 (1.5)	1 (1.4)
Emotional Exhaustion (EE)				< 0.001
Low	48 (34.0)	39 (57.0)	9 (12.0)
Moderate	47 (34.0)	29 (43.0)	18 (25.0)
High	45 (32.0)	0 (0.0)	45 (62.0)
Depersonalization (DP)				< 0.001
Low	59 (43.0)	45 (66.0)	14 (20.0)
Moderate	48 (35.0)	23 (34.0)	25 (36.0)
High	31 (22.0)	0 (0.0)	31 (44.0)
NA	2	0	2
Personal Accomplishment (PA)				< 0.001
Low	33 (24,0)	0 (0.0)	33 (46.0)
Moderate	52 (37.0)	28 (41.0)	24 (33.0)
High	55 (39.0)	40 (59.0)	15 (21.0)
¹n (%); Median (IQR)
²Pearson's Chi-squared test; Wilcoxon rank sum test; Fisher's exact test

Regional distribution showed no significant difference (p = 0.5), with 78% of the overall sample being from Western Urban. In the burnout group, 75% were from Western Urban, compared to 81% in the non-burnout group. Duration of practice did not differ significantly (p = 0.5), with 35% of the overall sample being house officers (HO), 39% medical officers (MO), and 26% senior medical officers (SMO). In the non-burnout group, 38% were HO, 41% MO, and 21% SMO, compared to 33% HO, 37% MO, and 30% SMO in the burnout group.

Lifestyle Factors and Burnout

Physical activity levels were similar between groups (p = 0.2), with 54% of the overall sample reporting 1–2 days of physical activity per week, followed by 24% reporting 3–4 days. In the burnout group, 60% reported 1–2 days of physical activity per week and 21% reported 3–4 days. Sleep duration showed a borderline significant difference (p = 0.054). Overall, 44% of participants slept less than 5 hours per night, with 50% in the burnout group and 37% in the non-burnout group. Self-reported overall health did not significantly differ (p = 0.3), with 59% of the overall sample reporting good health, followed by 27% reporting very good health. In the burnout group, 54% reported good health compared to 63% in the non-burnout group.

Burnout and Health Measures

The overall health perception did not significantly differ between the two groups (p = 0.3). However, when assessing burnout components, significant differences emerged. Emotional exhaustion (EE) differed significantly (p < 0.001), with 62% of the burnout group having high EE a, compared to none having high EE in the non-burnout group. Depersonalization (DP) also showed significant differences (p < 0.001), with 44% of the burnout group having high DP, while none of the non-burnout group had high DP. Personal accomplishment (PA) showed significant differences as well (p < 0.001), with 46% of the burnout group having low PA and none having high PA, compared to 59% of the non-burnout group having high PA and none having low PA. These findings indicate that physicians experiencing burnout were more likely to report high emotional exhaustion, high depersonalization, and low personal accomplishment compared to their non-burnout counterparts. Other demographic and lifestyle factors did not show significant differences between the groups.

Patient Care Practices

Physicians experiencing burnout were more likely to avoid performing diagnostic tests due to cost concerns, expedite patient discharge, and prescribe medication without proper evaluation (Fig. 1). These physicians also exhibited inadequate treatment management, often due to a lack of knowledge or experience, and were more likely to delay discussing treatment options due to high workload. In terms of patient care attitudes, burnout physicians reported higher frequencies of guilt regarding patient care, emotional distress from patient deaths, and neglect of the social and personal impacts of illnesses. These findings underscore the significant negative impact of burnout on both the quality of patient care and the emotional well-being of physicians.

In this cross-sectional study, we investigated the prevalence of burnout among physicians in major government hospitals in Sierra Leone. Additionally, we examined the association of burnout with various demographic, lifestyle, and health factors between April 2022 and July 2022. We found a high burnout rate of 51.4% among the 140 physicians in Sierra Leone. Burnout did not significantly differ across demographic factors such as gender, age, marital status, region, or years of practice.

Similarly, lifestyle factors like physical activity levels and self-reported overall health were comparable between the burnout and non-burnout groups. However, physicians experiencing burnout were more likely to report shorter sleep duration, with 50% sleeping less than 5 hours per night compared to 37% in the non-burnout group, although this difference was only borderline significant (p = 0.054). The key distinguishing factors were the three dimensions of burnout assessed by the Maslach Burnout Inventory (MBI): emotional exhaustion, depersonalization, and personal accomplishment, all of which showed significant differences between the two groups.

The high burnout prevalence of 51.4% among physicians in this study is consistent with findings from other low and middle-income countries (LMICs). A systematic review reported burnout rates ranging from 20.9–81% among healthcare workers in sub-Saharan Africa (12). Similarly, studies from Nigeria found burnout rates of 39.1% and 63.3% among doctors (13). The lack of association between burnout and demographic factors aligns with some prior research (14), but contrasts others that linked burnout to gender, age, and marital status (15). Interestingly, short sleep duration emerged as a potential risk factor, mirroring evidence from high-income settings (16, 17).

The significant differences in emotional exhaustion, depersonalization, and low personal accomplishment highlight the multidimensional nature of burnout and its impact on physicians' well-being and patient care attitudes. This is in line with findings from a systematic review of healthcare providers in sub-Saharan Africa, where high levels of emotional exhaustion were prevalent among physicians. In southern Ethiopia, 65.2% of physicians reported high emotional exhaustion (12). Similarly, among physician anaesthetists at a university hospital in South Africa, 45.2% reported high emotional exhaustion (12). In Nigeria, 57.8% of physicians undergoing residency training reported high levels of depersonalization (13), whereas, in Malawi, healthcare workers providing HIV care also reported high levels of depersonalization, with negative implications for patient care practices (18). Low personal accomplishment was another significant dimension of burnout observed in our study. This finding is corroborated by studies in other LMICs. For instance, in southern Ethiopia, 91% of physicians reported low personal accomplishment (12). In South Africa, both university hospital and private practice anaesthetists reported low personal accomplishment, with rates of 46% and 37.2%, respectively (12).

The high burnout prevalence underscores an urgent need to prioritize physician well-being in Sierra Leone's health system. Adequate workforce planning, optimized workloads, and improved working conditions are imperative to mitigate burnout risks (3). Interventions such as mindfulness training, resilience-building programs, and better access to mental health services may have a promising effect to mitigate burnout in LMICs (19). Additionally, fostering a supportive work culture, mentorship opportunities, and work-life balance initiatives could bolster physicians' sense of personal accomplishment and mitigate emotional exhaustion (20).

Furthermore, efforts should focus on addressing the broader systemic challenges that exacerbate burnout in resource-constrained settings. These include inadequate infrastructure, equipment shortages, financial constraints, and weak health workforce policies (21). Collaborative efforts between policymakers, healthcare leaders, and international stakeholders are crucial to develop contextually relevant, sustainable strategies that safeguard the well-being and retention of the healthcare workforce.

This is the first study to report on physician burnout prevalence in Sierra Leone. The use of a validated burnout assessment tool (MBI-HSS) enhances the reliability and comparability of the findings. However, the cross-sectional design precludes causal inferences, and the reliance on self-reported data may introduce recall bias. Future longitudinal studies and qualitative inquiries could provide deeper insights into the drivers and experiences of burnout among Sierra Leonean physicians. Other limitations associated with this study is the reliance on self-report measures, which may lead providers to provide insincere responses due to fear of administrative scrutiny. Additionally, the tools used to assess burnout and self-reported patient care practices and attitudes have not been validated in limited resource settings. However, this study offers a significant advantage in terms of the simplicity of administering assessment tools as the study population is well educated and accessible. Furthermore, the availability of a sampling frame in the form of a list of physicians facilitated efficient sampling.

This study reveals alarmingly high physician burnout in Sierra Leone, impacting patient care and well-being. Addressing burnout requires a multi-pronged, collaborative approach across individual, organizational, and systemic levels. Investing in healthcare worker well-being is crucial. Further longitudinal research is needed to inform contextually relevant interventions.

Human ethics approval and consent to participate

The present study received ethical approval from the Sierra Leone Ethics and Scientific Review Committee (SLESRC No.007/012024). Informed written consent was obtained from all participants prior to their enrolment in adherence with established ethical principles and protocols. Stringent measures were implemented to ensure the proper storage and management of the collected data. All methods were carried out in accordance with relevant norms, guidelines and regulations of the Sierra Leone Ethics and Scientific Review Committee.

Consent for publication

Not Applicable

Availability of data and materials

Data is available upon reasonable request to the second author, Dr. Mohamed Bella Jalloh ([email protected]). All authors recognise the value of sharing individual level data. We aim to ensure that data generated from all our research are collected, curated, managed and shared in a way that maximises their benefit.

Competing interests

Not Applicable

Funding

This work did not receive any funding.

Authors' contributions

All authors, AN, MBJ, SAAJ, AKB, AGJ, FBB, JVS, and AS, were involved in the conceptualisation and planning of the study. MBJ, SAAJ, AKB, AGJ and FBB were involved with conducting the study, with data collection.

AN, MBJ, AKB, JVS and AS were involved with the analysis and interpretation of data. AN and MBJ prepared the first draft of the manuscript. All authors, MBJ, AN, SAAJ, AKB, AGJ, FBB, AV, JVS and AS contributed to subsequent revisions to the manuscript. All authors, AN, MBJ, SAAJ, AKB, AGJ, FBB, JVS and AS, read and approved the final manuscript.

Authors' information (optional)

Not Applicable

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No competing interests reported.

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Physician Burnout and Patient Care Practices in Sierra Leone

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Abstract

Background

Methods

Results

Conclusion

Figures

Introduction

Method

Study design and population

Data collection, recruitment and outcomes

Statistical Analysis

Sample size and power

Results

Discussion

Strengths and limitations

Conclusion

Declarations

References

Additional Declarations

Supplementary Files

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