East Asian Arch Psychiatry 2024;34:58-64 | https://doi.org/10.12809/eaap2428
ORIGINAL ARTICLE
Leslie Lim Eng Choon, Gerard Michael Heng Yi Tong, Chan Yiong-Huak, Wong Hung Chew, Louis Loh Kai Miang, Leonard Eng Yong Tai, Cassandra Chan, Johnson Fam
Abstract
Background: This study aimed to investigate factors associated with burnout among healthcare workers (HCWs) in a tertiary hospital in Singapore.
Methods: All HCWs from the Singapore General Hospital were invited to participate in a survey using a secure online platform. Participant demographic data were collected. Instruments used included the Oldenburg Burnout Inventory (OLBI), the Connor-Davidson Resilience Scale, the Patient Health Questionnaire-4, a brief form of the Perceived Social Support Questionnaire, the Demand-Control- Support Questionnaire, and the Leisure Time Satisfaction Scale.
Results: Of 9888 staff, 742 (7.5%) responded. The mean OLBI score was 43.7, whereas the mean exhaustion subscale score was 22.5 and the mean disengagement subscale score was 21.2. Of the participants, 53.6% and 50.0% met the cut-off values for disengagement and exhaustion, respectively. In the linear regression analysis, those aged 20 to 29 years had higher OLBI scores than those aged ≥40 years (ß = 1.88, p = 0.001). Higher OLBI scores were associated with higher Patient Health Questionnaire-4 scores (ß = 0.52, p < 0.001), including the subscales of anxiety (ß = 0.30, p = 0.038) and depression (ß = 0.70, p < 0.001), lower scores for resilience (ß = -0.20, p < 0.001), particularly in the subscales of self- efficacy (ß = -0.37, p = 0.018) and cognitive focus (ß = -1.02, p < 0.001), higher psychological demand subscale scores (ß = 0.62, p < 0.001) and lower decision latitude subscale scores (ß = -0.33, p < 0.001) and lower social support subscale scores (ß = -0.47, p < 0.001), and lower Leisure Time Satisfaction Scale score (ß = -0.55, p < 0.001).
Conclusion: Among HCWs in a Singaporean hospital, burnout was associated with age <40 years, the presence of anxiety and depressive symptoms, low resilience, high psychological demands and low decision latitude and social support, and low leisure time satisfaction.
Key words: Anxiety; Burnout, professional; COVID-19; Depression; Health personnel
Leslie Lim Eng Choon, Department of Psychiatry, Singapore General Hospital, Singapore
Gerard Michael Heng Yi Tong, Department of Psychiatry, Singapore General Hospital, Singapore
Chan Yiong-Huak, Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
Wong Hung Chew, Biostatistics Unit, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
Louis Loh Kai Miang, Department of Psychiatry, Singapore General Hospital, Singapore
Leonard Eng Yong Tai, Department of Psychiatry, Singapore General Hospital, Singapore
Cassandra Chan, Department of Internal Medicine, Singapore General Hospital, Singapore
Johnson Fam, Department of Psychiatry, Singapore General Hospital, Singapore
Submitted: 10 June 2024; Accepted: 6 August 2024
Healthcare workers (HCWs) face life-threatening situations, potential exposure to pathogens, long working hours, major changes in work routines, and patients dying from their illnesses.1 During the COVID-19 pandemic, frontline HCWs experienced high levels of stress,2 with many developing psychological symptoms.3 High stress can affect well-being and work performance and can lead to burnout4,5 and eventually suicide.6
Although it is not classified as a psychiatric condition, burnout is included in the ICD-11 as an occupational phenomenon characterised by energy depletion, increased mental distance from one’s work, and reduced professional efficacy.7 The highest levels of burnout are reported among HCWs working in emergency and intensive care units, where they are exposed to an overwhelming amount of stress.8,9 Burnout results in reduced quality of patient care, medical errors, and high absenteeism and turnover among HCWs.5,8
Risk factors for burnout include working in locations with high patient mortality rates, exhaustion, depression, anxiety, decreased professional satisfaction, and young age.10 Infrequent contact with family members is also associated with burnout.11 Perceived social support can mitigate emotional exhaustion and increase subjective sense of well-being.12
In Singapore, HCWs report high levels of burnout.13 In a 2022 multi-hospital study, 38% of staff reported emotional exhaustion, 30% had high levels of depersonalisation, and 55% scored low on personal accomplishment; however, factors associated with burnout were not assessed.14
Our study was conducted during the post-COVID period when Singapore was transitioning from a policy of ‘zero-COVID’ to that of ‘living with COVID’. We aimed to investigate factors associated with burnout among HCWs in a tertiary hospital in Singapore. We hypothesised that burnout was higher among females, those who were single, foreign-born staff or recent immigrants, those whose family was not living in Singapore, those with lower levels of resilience, and those with lower levels of perceived social support.
All HCWs from the Singapore General Hospital were invited to participate in a survey conducted between 13 September 2022 and 12 March 2023. Those with no access to corporate emails were excluded. Questionnaires written in English were sent via corporate email using a secure online platform (FormSG, GovTech, Singapore). Weekly reminders were sent to encourage participation. No financial rewards were offered.
Participant demographic data were collected. Instruments used included the Oldenburg Burnout Inventory (OLBI), the Connor-Davidson Resilience Scale, the Patient Health Questionnaire-4 (PHQ-4), a brief form of the Perceived Social Support Questionnaire, the Demand- Control-Support Questionnaire, and the Leisure Time Satisfaction Scale.
The OLBI for burnout comprises 16 items in two dimensions (exhaustion and disengagement).15 Each dimension consists of eight items rated on a four-point Likert scale from 1 to 4. Total scores range from 16 to 64; higher scores indicate higher levels of burnout. Although the Maslach Burnout Inventory16 is the gold standard in assessing burnout, the OLBI measures the physical and cognitive components of exhaustion. The OLBI was used in a previous Singaporean study14 and therefore selected to facilitate comparison.
The Connor-Davidson Resilience Scale is a 10-item self-report unidimensional scale.17 Each item is rated on a five-point Likert scale from 0 (not true at all) to 4 (true nearly all the time); higher scores indicate higher levels of resilience.
The PHQ-4 comprises four items and measures core symptoms and signs of depression and anxiety.18 Each item is rated on a four-point Likert scale; total scores are rated as normal (0-2), mild (3-5), moderate (6-8), and severe (9-12). Total scores of ≥3 for first two questions suggest anxiety, whereas total scores of ≥3 for the last two questions suggest depression.
The brief form of the Perceived Social Support Questionnaire is a six-item, reliable, valid, and economical instrument.19 Each item is rated on a five-point Likert scale from 1 (not true at all) to 5 (very true); higher scores indicate higher levels of perceived social support.
The Demand-Control-Support Questionnaire comprises 17 items in three subscales that assesses employees’ perception in terms of psychological demands, control/decision latitude, and social support of their jobs.20 Each item is rated on a four-point Likert scale; higher subscale scores indicate higher perceived levels. The demand subscale comprises five items and evaluates psychological pressure in terms of time, effort, and speed required to complete a task. The control or decision latitude subscale comprises six items and assesses cognitive abilities in the execution of occupational tasks and the degree of autonomy in executing such tasks. The social support subscale comprises six items and evaluates work-related social supports. The latter subscale differs from the brief form of the Perceived Social Support Questionnaire, which assesses perceived social support outside of work.
The Leisure Time Satisfaction Scale21 comprises six items rated on a three-point Likert scale from 0 (not at all) to 2 (a lot); higher scores indicate higher leisure time satisfaction. It has excellent psychometric properties, including internal consistency, a single factor structure, and convergent validity.
Analyses were performed using Stata version 17.0 (StataCorp). All tests were two-sided; a p value of 0.7) and good internal consistency (comparative fit index of >0.9) except for the psychological demand and decision latitude subscales of the Demand-Control-Support Questionnaire, which showed suboptimal reliability, and for the OLBI and the decision latitude subscale, which showed suboptimal internal consistency (Table 1). Factors associated with OLBI scores were determined using linear regression analyses.
Of 9888 staff, 742 (7.5%) responded. Of these, 61.0% were aged <40 years, 73.2% were female, 53.0% were married, 86.7% had family members living in Singapore, and 42.5% were nurses (Table 2). The mean OLBI score was 43.7, whereas the mean disengagement subscale score was 21.2 and the mean exhaustion subscale score was 22.5. Of the participants, 53.6% and 50.0% had the disengagement and exhaustion subscale scores above the mean, respectively. In addition, 38.7% had anxiety and 31.8% had depression, based on the cut-off values of ≥3 in the PHQ-4 subscales.
Higher levels of burnout were associated with ‘other’ sex, work duration of <10 years, age <40 years, allied health professionals and nurses, being single, higher anxiety and depression levels, lower resilience, higher psychological demand and lower decision latitude and social support, and lower leisure time satisfaction.
In the linear regression analysis, those aged 20 to 39 years had higher OLBI scores than those aged ≥40 years (ß = 1.88, p = 0.001). Specifically, those aged 20 to 29 years (ß = 3.33, p = 0.004) and those aged 30 to 39 years (ß = 3.02, p = 0.003) had higher OLBI scores than those aged ≥60 years. Higher OLBI scores were associated with higher PHQ-4 scores (ß = 0.52, p < 0.001), including the subscales of anxiety (ß = 0.30, p = 0.038) and depression (ß = 0.70, p < 0.001), lower scores for resilience (ß = -0.20, p < 0.001), particularly in the subscales of self-efficacy (ß = -0.37, p = 0.018) and cognitive focus (ß = -1.02, p < 0.001), higher psychological demand subscale scores (ß = 0.62, p < 0.001) and lower decision latitude subscale scores (ß = -0.33, p < 0.001) and lower social support subscale scores (ß = -0.47, p < 0.001), and lower Leisure Time Satisfaction Scale score (ß = -0.55, p < 0.001).
Our results suggested that HCWs aged <40 years had higher burnout scores, consistent with other studies.22-25 However, one study reported higher burnout scores with increasing age.26 Reductions in cognitive resources in older adults may lead to greater difficulty in dealing with intellectually demanding tasks that require retention of large amounts of information and rapid cognitive processing.27-29 Older adults need to expend greater effort than younger adults to maintain the same level of task performance.30
Sex of HCWs was not associated with burnout, consistent with one study10 but not another.31 Women are at higher risk of developing physical exhaustion and depersonalisation,32 owing to having more work-family conflicts than men.10,33 Women are more likely to be the principal care provider in the family34 and therefore have to balance work and family.
Younger HCWs are often placed in frontline positions. Older HCWs, often being supervisors and managers, have fewer patient contacts. Younger doctors are more empathetic and idealistic and hence at higher risk for burnout.35 In the early stages of their careers, younger workers need to master job requirements10,36 and deal with work-family conflicts.37 However, with successful job mastery, workers better adapt to work demands, and burnout and work-family conflicts decrease with increasing age, thereby reducing the propensity for burnout.38
The association between age and burnout can be bimodal in women, with those aged 20 to 35 years and those aged >55 years showing the highest levels of burnout.32 Those aged 35 to 55 years have reduced burnout symptoms.39 This could imply a greater adaptation to work stressors conferred by work experience.
Although resilience seemed to be a protective factor against burnout, the concept of resilience should not be encapsulated in a single total score; subscale scores can more accurately describe which aspects of resilience help mitigate burnout.
HCWs with higher anxiety and depression scores had higher burnout scores, consistent with previous studies.12,40 The causal relationship between burnout and symptoms of anxiety and depression could not be established in our crosssectional study. Associations between anxiety, depression, and burnout are not straightforward, as there are overlapping features between the three conditions. However, burnout can be empirically distinct from depression and anxiety.41 In our study, although both depression and anxiety were associated with the burnout scores, the association was stronger with depression than with anxiety, consistent with one study.42
Foreign-born HCWs who are separated from their families have higher anxiety and depressive scores.12 We hypothesised that these HCWs who have lived a longer duration in Singapore would be more acclimatised to local conditions. Similarly, having immediate family living in Singapore would provide support and protect against doctorburnout. However, none of these factors were significantly associated with burnout. What seemed to protect against burnout was whether foreign-born staff had the opportunity to return to their home country to visit their family in the previous year.12
Perceived social support is associated with a reduced risk of depression43 and mediates against burnout.13,44 However, perceived social support was not significantly associated with burnout in our study. This may be because when HCWs encountered stress at work, they may have received support from colleagues and superiors rather than outside sources. The brief form of the Perceived Social Support Questionnaire skews towards support from outside of the workplace. For HCWs, leisure activities provided better respite than perceived social support.
According to the Karasek’s job demand-control model,45-47 jobs comprise two dimensions: the psychological demands and the control to meet these demands. Thus, high work demands tend to lead to high levels of stress, but high levels of control can moderate the stress caused by high demands. In our study, having high psychological demands was associated with burnout, whereas having high decision latitude and work-related social support mitigated against burnout.
There are limitations to our study. The crosssectional study design cannot draw causal inferences. The sample was not representative, as only 7.5% of hospital staff participated in the survey. Those with a higher risk of burnout may or may not have been more willing to participate. Those without access to corporate emails (ie, lower grade staff) were excluded. The sample was from a single tertiary hospital; however, it was representative of other general hospitals in Singapore. Complex cases are often referred to our hospital, and our staff are more likely to experience burnout. Self-reported data might be subject to social desirability bias. However, confidentiality was ensured, and questions about departments and job grades were omitted. We expected responses to be candid. In addition, there were no missing data. Some questions were omitted to reduce the time required to complete the survey. For instance, we would have investigated the relationship between parenthood and burnout, as having children comes with caregiving duties. Burnout is more likely to occur when domestic stress is added to work stress.34
Among HCWs in a Singaporean hospital, burnout was associated with age <40 years, the presence of anxiety and depressive symptoms, low resilience, high psychological demands and low decision latitude and social support, and low leisure time satisfaction. Reducing workload, improving work schedules, promoting self-management, and teaching physical, mental, and emotional self-care, and other stress management activities are effective techniques to reduce burnout.48,49
All authors have disclosed no conflicts of interest.
This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
All data generated or analysed during the present study are available from the corresponding author on reasonable request.
The SingHealth Centralised Institutional Review Board granted exemption of participant consent, in view of the study being categorised as ‘anonymous, educational tests, surveys, interviews or observation’ (reference: 2002/2004).
We thank Ms Nurhasinah binte Omar for her secretarial assistance.
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