Assessment of burnout levels among anesthesiologists and anesthesiology technicians in Kosovo: A cross-sectional study

Abstract

BACKGROUND:

Anaesthesiology practitioners experience extraordinary pressure and stress in their daily work.

OBJECTIVE:

The purpose of this research is to assess the occupational factors and burnout syndrome among anaesthesiologists and anaesthesiology technicians in Kosovo.

METHODS:

This is a cross-sectional study carried out on a sample of 154 (out of 220) anaesthesiologists and anaesthesiology technicians in Kosovo. We collected the data using the Maslach Burnout Inventory and Occupational Role Stressors Scale.

RESULTS:

The mean ± SD age of the study sample was 42.5 ± 8.7 years, and 57% of them were working more than 40 h per week. A high level of burnout in terms of depersonalization (DP) was found among 48 of anaesthesiologists and anaesthesiology technicians, 26 had high level of emotional exhaustion (EE). EE and DP showed significant positive correlation with work overload, managerial responsibility role, and overall occupational stress (p < 0.05). Female anaesthesiologists and anaesthesiology technicians showed higher score of personal achievement (PA) compared to males (p < 0.05).

CONCLUSION:

Approximately one-third of Kosovar anaesthesiologists and anaesthesiology technicians showed high level of burnout and it is rising as work overload and the role of managerial responsibility increases. Increasing the number of employed anaesthesiologists and anaesthesiology technicians in health institutions in Kosovo will lead to a better workload distribution and lower burnout syndrome.

Keywords

Cross-sectional study burnout MBI anaesthesiology stress

1. Introduction

Anaesthesiology practitioners need to be continuously vigilant in the event of potential emergencies and must be able to handle crises that may occur at any time in the operating room utilizing all their knowledge, skills, dexterity, and proper attitudes for a good clinical practice [1]. This exerts extraordinary pressure and stress in their daily work and thus affects their wellbeing, rendering anaesthesiology a stressful profession [2–5].

Stress is most often considered an essential part of work commitment and responsibilities but when it becomes extensive and prolonged it leads to “burnout” which is a condition defined as a psychological syndrome of emotional exhaustion, depersonalization, and professional achievements [6,7]. Studies show that approximately 25% of anaesthesia practitioners are at high risk of developing burnout syndrome [2,8].

Emotional exhaustion is considered as the initial sign of burnout syndrome and it is mainly caused from the mismatch between the demands and personal abilities to achieve those demands. Emotional exhaustion refers to the physical and mental over-load which derives from the continuous interaction with patients and colleagues. Depersonalization is characterized by emotional instability and development of negative and cynic attitudes in relation to clients. Lack of personal achievement is followed by a negative self-assessment due to the lack of satisfaction in the workplace [9–11].

Burnout syndrome tends to be related to several organizational stressors what has stimulated many researchers to focus on job stress [12]. About 50–96% of anaesthesiologists have been reported to be suffering occupational stress to the highest levels [13], arising mainly from the disproportion between the demands being made and the ability to meet these demands [14] and due to the lack and maldistribution of anaesthesiologists [15].

Different studies conducted with anesthesiology practitioners have shown association between burnout and such socio-demographic variables as age, female sex, night shifts, high career stage and high workload [9,16–23].

Anaesthesiologists cannot afford excessive workloads because of their practice, which might not be safe [6] especially in those cases when they are responsible for more than one patient at the same time, for instance the mother and child during caesarean section [24].

In addition, other causes of burnout syndrome are related to the pressure to produce positive outcomes in the workplace, interactivity within the workplace especially the interactivity and relationship with surgeons where role ambiguity might occur due to the lack of a defined boundaries between both roles [25].

Inadequate working conditions are a major cause for the development of work stress that, together with decrease in work productivity, increase of exhaustion and depersonalization, are a threat to professional errors and patient safety [26]. In addition, high levels of stress and burnout syndrome also contribute to increasing the level of economic burden of training and recruiting new staff members [27].

As a developing country in Europe, Kosovo has a small workforce in the field of anaesthesiology, with 4.54 anaesthesiologists and 8.10 anaesthesiology technicians per 100 000 inhabitants. In our country anaesthesiology technician (who are mainly graduated from the nursing program and after that attending short training for anaesthesiology technician) assist anaesthesiologists set up and turnover the rooms, and also monitor the patient’s condition under the supervision of anaesthesiologists in the Central Intensive Care Unit, and in operating rooms in the University Clinical Center of Kosovo and general hospitals. Regular working hours of 40 h per week are standard, in addition in some units 12 or 24-h shifts are practical work organization for both anaesthesiologists and anaesthesiology technicians.

To the best of our knowledge this is the first study of this kind which reveals results on burnout syndrome and occupational stress of anaesthesiologists and anaesthesiology technicians in Kosovo. This research assessed the occupational factors and burnout syndrome among anaesthesiologists and anaesthesiology technicians in Kosovo.

2. Materials and methods

This cross-sectional study was carried out on a sample of 154 anaesthesiologists (53 out of 79) and anaesthesiology technicians (101 of total 141), which corresponds to a response rate of 70% of the entire staff working in health institutions in Kosovo. We used the convenient sampling as a sampling technique. We excluded the staff that were on medical leave or vacation during the data collection period. Also, we obtained informed consent from all the physicians and anaesthesiology technicians and they were requested to complete the questionnaire given to them. Upon attaining the consent, we briefly explained the aim of this study. We kept the information provided by the physicians and anaesthesiology technicians confidential and only utilized it for the purpose of this study. The procedures in this study are in complete compliance with the provisions of the Declaration of Helsinki related to research on human participants.

To measure organizational stressors, we used the Occupational Role Stressor (ORS) developed by Osipow and Spokane [28]. To measure the burnout level, we used Maslach Burnout Inventory by Maslach, Jackson et al. [29]. We individually analysed each of the sub-scales: emotional exhaustion (EE), depersonalization (DP) and personal achievement (PA). MBI categorizes the subscale score of EE 0–17 as “low-level burnout”, the total between 18–29 as “moderate burnout” and total over 30 as “high-level” burnout. For DP, MBI categorizes 0–5 as “low-level” burnout, total between 6 and 11 as “moderate” burnout and the total of 12 and higher as “high-level” burnout. For PA, MBI categorizes 0–33 as “high-level burnout”, 34–39 as “moderate burnout” and >39 as “low-level” burnout.

We summarized the continuous variables as mean ± Standard Deviation (SD) or median and IQR (Inter Quartile Rate), and categorical variables as frequency (n) and percentages (%). We used the Pearson correlation coefficient to examine the relation between burnout level and occupational role stressors. To find the differences between groups, we used the independent t-test and One-way ANOVA. We conducted the analysis using IBM SPSS v21 considering p < 0.05 as statistically significant.

3. Results

Out of 154 anaesthesiologists and anaesthesiology technicians who completed the questionnaires, 56% worked at the tertiary level and 44% worked at the secondary level. The mean ± SD age of the study sample was 42.5 ± 8.7 years, and 57% of them work more than 40 h per week. The distribution and frequency of their gender, age, education, work experience and working hours per week are summarized in Table 1. A high level of burnout in terms of depersonalization was found among 48 out of 154 anaesthesiologists and anaesthesiology technicians, 26 out of 154 had high level of emotional exhaustion and with regard to PA, and only 4 out of 154 had a high level of burnout (Table 2). EE and DP showed positive significant correlation with work overload (p < 0.05), managerial responsibility role (p < 0.05), and overall occupational stress (p < 0.05). There was no statistically significant correlation between the physical environment and DP and EE scores (p > 0.05) (Table 3).

Table 1
Socio-demographic and work-related characteristics

Age (years) n %

21–30 14 9

31–40 54 35

41–50 55 36

51–60 28 18

>60 3 2

Sex

Female 87 56

Male 67 44

Education

High-school 66 43

University 88 57

Profession

Anaesthesiologist 53 34

Anaesthesiology technician 101 66

Work experience (years)

1–15 63 41

16–30 82 53

31–45 9 6

Working hours per week

>40 88 57

40 66 43

Age (years)	n	%
21–30	14	9
31–40	54	35
41–50	55	36
51–60	28	18
>60	3	2
Sex
Female	87	56
Male	67	44
Education
High-school	66	43
University	88	57
Profession
Anaesthesiologist	53	34
Anaesthesiology technician	101	66
Work experience (years)
1–15	63	41
16–30	82	53
31–45	9	6
Working hours per week
>40	88	57
40	66	43

Table 2

Maslach Burnout Inventory scores by subscales

Subscale	Median (IQR)	Low level of burnout n (%)	Moderate level of burnout n (%)	High level of burnout n (%)
Emotional exhaustion	13.0 (9.0–23.0)	96 (62.3)	32 (20.8)	26 (16.9)
Depersonalization	9.0 (7.0–14.0)	0	106 (68.8)	48 (31.1)
Personal achievement	56.0 (51.0–56.0)	146 (94.8)	4 (2.6)	4 (2.6)

IQR-inter quartile rate.

Table 3

Correlation between MBI (emotional exhaustion score, depersonalization score, personal accomplishment score) and ORS (work over-load, responsibility role, physical environment)

	MBI			ORS
	EE	DP	PA	Work overload	Responsibility role	Physical environment	Overall occupational stress
EE	1
DP	0.588^∗	1
PA	0.027	0.052	1
Work overload	0.494^∗	0.437^∗	−0.047	1
Responsibility role	0.547^∗	0.409^∗	−0.054	0.621^∗	1
Physical environment	−0.104	−0.119	0.124	−0.016	−0.275	1
Overall occupational stress	0.401^∗	0.316^∗	0.066	0.562^∗	0.407^∗	0.602^∗	1

^∗-Statistically significant (p < 0.05); MBI-Maslach Burnout Inventory; ORS-Occupational stress; EE-Emotional exhaustion; DP-Depersonalization; PA-Personal achievement.

Female anaesthesiologists and anaesthesiology technicians showed a higher score of personal achievement compared to males (Table 4).

Table 4

Univariate analysis of MBI scores in relation to demographics profile of the participants

			MBI subscales score (mean ± SD)
Characteristics		n (%)	Emotional exhaustion (EE)	p	Depersonalization (DP)	p	Personal achievement (PA)	p
Sex	Male	67 (43.5)	18.90 ± 12.7	0.343	11.30 ± 5.04	0.695	51.81 ± 9.08	0.005^∗
	Female	87 (56.5)	17.00 ± 11.8		10.95 ± 5.65		52.29 ± 7.17
Education	High school	66 (42.9)	16.70 ± 11.84	0.324	10.445 ± 5.17	0.185	50.91 ± 10.1	0.028^∗
	Faculty/University	88 (57.1)	18.67 ± 12.54		11.60 ± 5.50		52.95 ± 5.82
Experience (years)	1–15	63 (40.9)	17.17 ± 11.74	0.183	11.22 ± 5.44	0.420	2.86 ± 0.470	0.427
	16–30	82 (53.2)	17.67 ± 12.48		10.82 ± 5.34		2.93 ± 0.344
	31–45	9 (5.8)	23.78 ± 13.43		12.89 ± 5.55		—
Number of current workplaces	1	103 (66.9)	17.56 ± 11.90	0.314	11.00 ± 5.13	0.121	51.16 ± 8.73	0.634
	2	44 (28.6)	17.34 ± 11.58		10.70 ± 4.67		52.71 ± 7.75
	≥3	7 (4.5)	24.71 ± 20.02		15.14 ± 10.60		52.78 ± 4.23
Weekly workload (hours)	40	66 (42.9)	18.39 ± 12.40	0.808	11.53 ± 5.31	0.098	51.47 ± 8.83	0.220
	>40	88 (57.1)	17.08 ± 12.10		10.53 ± 5.46		53.16 ± 6.24
Managerial role	Yes	30 (19.5)	21.50 ± 14.90	0.030*	11.03 ± 6.45	0.364	52.07 ± 9.74	0.937
	No	124 (80.5)	16.94 ± 11.4		11.12 ± 5.11		52.08 ± 7.58

^∗-Statistically significant (p < 0.05).

4. Discussion

The main findings of this study show that about one third of anaesthesiologists and anaesthesia technicians in Kosovo experience a high level of burnout which is correlated to the overall occupational stress, work overload, and managerial responsibility role. Similar to our findings the results of a study conducted in US by Shah et al. show that 26% of anaesthesia providers experience high levels of emotional exhaustion, whilst another study conducted in Australia has reported that 20% of anaesthesiologists experience high levels of emotional exhaustion and depersonalization and 37% experience high level of burnout regarding personal achievement [30,31]. Despite the difference in monthly earnings between anaesthesia workers in Kosovo and those in economically developed countries, there is no substantial difference in burnout rate. There are other factors that have to be considered when it comes to burnout and occupational stress.

The studies of Vichitvejpaisal and Mahatnirunkul, and Turk et al., showed that workload and night shifts are the main concerns of anaesthesiology technicians and they are a permanent source of stress among doctors [22,23]. While results of a study on UK physicians showed a correlation between emotional exhaustion and stress [32], other results from the study by Kluger et al. showed that clinical problems cause the least stress while organizational factors contribute to a higher degree of stress and burnout [31]. Moreover, the results of a study conducted in Japan by Kawasaki et al. indicate that anaesthesiologists working on an average of 48 h per week experience an above average level of occupational stress due to a list of factors as work-load, responsibility and lack of experience [24]. However, in our study we found no difference on the burnout level between those working 40 h per week compared to those working more than 40 h per week.

This study found that the majority of anaesthesiology practitioners work more than 40 h a week, which is an indicator of a shortage of the labor force in this sector in Kosovo. The low number of anaesthesiologists and anaesthesiology technicians in Kosovo is attributed, first and foremost, to political instability over the last two decades, lack of budget and investment in the health sector, and insufficient and comprehensive national strategy for the anaesthesiology workforce.

5. Conclusion

Approximately one-third of Kosovar anaesthesiologists and anaesthesiology technicians have shown high level of burnout and it is rising as work overload and the role of managerial responsibility increases. Increasing the number of employed anaesthesiologists and anaesthesiology technicians in health institutions in Kosovo will lead to a better workload distribution and lower burnout syndrome. Raising awareness of emotional wellbeing and the threat of burnout syndrome in anaesthesiology workforce through various campaigns, scientific research papers, and policy initiatives geared at policy-makers will result in improving working conditions for anaesthesiology staff in developing countries such as Kosovo [33].

Footnotes

Conflict of interest

None to report.

Funding

None to report.

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