Introduction

Burnout has become a common challenge faced by employees within any dynamic work environment regardless of their profession. Initially, the term burnout was introduced by Freudenberger H. J., an American Psychologist and writer, who has been awarded the Gold Medal Award for Life Achievement in the Practice of Psychology.¹ He defined it as “exhaustion resulting from excessive demands on energy, strength or resources in the workplace”, which can lead to the development of adverse psychological as well as physical symptoms such as decreased work efficiency, frustration, cynicism, and fatigue.¹ He described the process as a “gradual emotional depletion and a loss of motivation and commitment” as time progressed.² It has officially been recognized as a psychiatric medical diagnosis by the World Health Organization (WHO), in May 2018.3

Although it affects all professions with varying severity, the incidence of burnout amongst Health Care Workers (HCW) has become an important issue in recent years owing to its potential harm and negative consequences on the medical staff and on the patient’s quality of care.¹ Approximately one in three physicians experiences burnout at any given time.⁴ It has also been witnessed that increasing the degree of burnout, increases the likelihood of a medical error.^4,5

A study published in the US in 2012 stated that physicians were more likely to have symptoms of burnout relative to others in different career paths and be discontent with their work-life balance.³ Another study in the US during 2007 found that burnout among medical students seemed to be associated with an increased likelihood of subsequent suicidal ideation.⁶

With the emergence of the global pandemic, initiated by the newly discovered SARS CoV-2 (COVID-19) virus, commonly known as Novel Coronavirus, HCWs were faced with unprecedented conditions and new challenges which led to an increase in work stress. The outbreak which started in the city of WuHan, China spread rapidly across the world in December of 2019 and on January 30^th, 2020 the WHO announced that the pandemic was a public health emergency.⁷

Preventative measures were implemented to ensure safety for all citizens and nationals. HCW from all fields and specialties were recruited in response to the outbreak. However, COVID-19 cases continued to rise and reached up to a total of 21,8047 on 23^rd May 2021 in comparison to only a total of 8,971 cases back on the same day March 23rd, 2020.^9,10 This added to the risk of increased levels of burnout amongst HCWs as they were required to handle the incline of cases as time progressed.

Several research has been previously conducted on physician burnout in Bahrain. However, since the outbreak began, it could possibly contribute to higher stress levels and burnout prevalence may significantly related to it. None of the previous burnout studies in Bahrain included both physicians as well as nurses. This encouraged us to dwell into this research, making it the first in Bahrain in tackling the incidence of the psychological impact of burnout in HCW.

The main objective of this research is to investigate the prevalence of burnout amongst HCW in the Kingdom of Bahrain, and its associated factors. Factors include age, gender, nationality, marital status, presence of children, years of experience, and sector of work. The HCW currently employed in government and private hospitals were the target sample of the research.

Methodology

There are various methods to evaluate burnout, provided by the National Academy of Medicine, this includes the Maslach Burnout Inventory (released in 1981), the Oldenburg Burnout Inventory (released in 2002), as well as the Copenhagen Burnout Inventory, a survey released in 2005 which we implemented in our study.¹¹ The survey was sent out mid-October to 300 HCW. The survey was closed at the end of October, with a total of 281 responses.

Our questionnaire was modeled on the Coenhagen survey because it evaluates three aspects of burnout including personal life, work life, and client-based; in which “client” refers to an entity such as a patient.¹¹ The questionnaire includes a total of 19 items measuring overall physical and psychological fatigue.¹¹ Questions 2 - 7 assessed personal burnout, whereas questions that followed were used to assess work-related burnout. Before proceeding with the survey, the term burnout was clearly defined to the participant.

In addition to the burnout questions, the survey included other variables that may contribute to an increased level of burnout. This information includes participant demographic details such as gender, age, years of experience, sector of work (Government or private), marital status, nationality, and presence of children.

The inclusion criteria for this research were practicing physicians and nurses who were currently practicing in the medical field. Retired HCW, medical students or HCW who have not been in clinical practice over the past 2 years, were excluded. After constructing the questionnaire, it has been reviewed and approved by the Primary Health Care Research Committee. Following which it has been uploaded on Google^® Forms and sent out in October 2021. The survey was sent out randomly and electronically via Whatsapp^® to the physicians and nurses practicing in both governmentas well as private hospitals and was filled anonymously with the data recorded online. Data provided by the responders was kept confidential. Participation in this research was entirely voluntary, as an informed consent has been taken before proceeding with the questionnaire. Data analysis was done using the SPSS version 24 and a Chi Square test was done to calculate statistical significance. Burnout was considered the dependent variable.

Results

Table 1 demonstrates the demographic deails of the participants, the majority of which were females constituting 212 (74.0%) from a total of 281 participants. Bahraini nationals formed the majority with241 (86.8%) followed by Indians 30 (10.7%) with only a minority of other nationalities such as Jordanian, Pakistani, and Syrian.

Most of the respondents were married as seen in 184 (65.4%) participants out of which 138 (49.2%) had children. As noticed in Table 1, most participants 265 (95%) were from the Government Sector. Slightly more than half the participants, 160 (56%), reported having 0 - 5 years of experience, whereas 46 (16.3%) had more than fifteen years of experience. Moreover, in regards to profession, 180 (64.0%) of participants were practicing physicians whereas 101 (36.0%) were nurses.

Table 2 shows the responses to the personal and work-related burnout questions. It shows that 165 (58.7%) of participants worked in a High-Risk Environment (HRE) whereas, only 38 (13.5%) participants replied that they seldom or never experienced burnout. This demonstrates that 243 (86.5%) of participants experience burnout on a regular basis, either sometimes (39.5%), often (24.9%) or always (22.1%).

Discussion

HCW are at an increased risk of depression, anxiety, and burnout due to the nature of their profession as well as the number of hours spent at work.¹ This risk increased due to the overwhelming workload. The purpose of this research was to find the prevalence of burnout amongst HCW and its related factors, in the Kingdom of Bahrain. Research participants reached a total of 281 respondents.

A higher number of responses came from younger participants, 147 (52.3%). As age increased, the number of participants decreased with with only 14 (5%) above 50 years. This can be explained by the fact that most participants are from younger age groups which means they are junior doctors and nurses and naturally will have more physically demanding duties in the start of their careers.

Statistical analysis of questions in Table 2 revealed that all of the questions were statistically significant having a p-value of less than 0.05; except questions number 9 and number 11 having p values of 0.071 and 0.060 respectively. This meant that participants were not exhausted at the idea of another day of work and still had energy to spend leisure time with family members and friends. Furthermore, when asked about whether these symptoms increased with time, 217 (77.2%, p-value <0.001) respondents reported to have experienced more burnout and 52 (18.5%) of which reported that the symptoms of burnout have increased significantly over time, whereas 70 (24.9%) has remained the same and only a total of 24 (8.5%) reported symptoms to have decreased with time. This could a result of increase in responsibilities as career progresses. The COVID-19 pandemic could also be a major distributing factor leading to an increase in burnout among HCW during this period.

A study conducted in Bahrain, in January 2020 depicted a burnout prevalence of 41.2% among primary health care physicians.¹⁴ This is significantly lower than the rates reported in our study (86.5%). This indicates a noticeable increase in burnout during this dictated period. The study sample in the comparative study only included primary care physicians whereas, here we included both nurses and physicians in tertiary as well as primary care centers and thus could have affected the responses. It was also found that higher rates of Emotional Exhaustion (EE) have been associated with female gender and an increased age of the physician.¹⁴ This is not comparable to our study as gender was not a statistically significant (p-value 0.450) indicator of burnout and younger age groups reported significantly higher rates of burnout than their older counterparts.

Another study published in Lithuania in May 2020 regarding the level of burnout among Lithuanian hospital physicians demonstrated high rates of work and personal related burnout with 46.7% and 44.8% respectively, which is still lower than the rates noted in our study.¹² The same study emphasized that participants that have high levels of burnout more frequently did not have any children and were single.¹² Compared to these findings, neither marital status nor children had a significant impact, p- values 0.221 and 0.122 respectively, on burnout rates. This could reflect the higher demands on HCWs during the current situations leading to higher burnout rates affecting both single and married workers irrespective of the presence of children. HCW, from private and public sectors, practicing in HRE constituted more than half (58.7%) of the total respondents; this could explain the high level of burnout, as these HRE require more physical and mental efforts and may lead to more exhaustion in relative to other work areas.

Limitations to this study include that the majority of responses were from women which may perhaps be attributed to the fact that the study included nurses who are mostly female in gender. Another limitation is the fact that most of the responses were from younger age groups with naturally less experience, the less experience and lower familiarity with the workplace can potentially affect stress levels and feelings of burnout.

Conclusion

In conclusion, it is clear that burnout levels amongst HCW in Bahrain are high and evidence suggests that they are increasing over time. However, neither gender nor the presence of children were variables that were correlated significantly with burnout. We have found that burnout has been associated with higher levels of emotional and physical exhaustion. HCW working in HRE were more susceptible to burnout. Further studies should be conducted in the future to include a more diverse amount of health care workers including technicians, auxiliary staff, laboratory workers, etc. to get a more comprehensive view of the prevalence of burnout and ways to mitigate its effects like counseling, meditation, good work distribution should be implemented.

Conflict of Interest

The authors have no conflict of interest to disclose.

Acknowledgment

Special thanks to Mr Ali Al Sadeq, Data analyst Officer at The Benefit Company, Bahrain, Member of Bahrain Economists Society, for his help with data analysis.