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More than 200 countries globally are impacted by the spread of novel coronavirus, a pathogen responsible for causing COVID-19, the most debilitating disease of the era. The healthcare systems are frantically maximizing their efforts to mitigate the spread and reduce COVID-19 associated mortality and morbidity. A potential increase in actions and excessive workload to cope lack of vital resources and extra work resulted in compounded stress and burnout among health care professionals in the wake of this global crisis. [1]
Burnout can be defined as a syndrome characterized by exhaustion, cynicism, and reduced effectiveness. Various factors such as; increased workload hours, limited resource availability, inadequate treatment guidelines, higher infection rates among health care workers and safety concerns have significantly contributed to increased physician burnout in pandemic time. It substantially affects physician turnover, quality of care, patient safety and satisfaction. Along with professional implications, it also impacts mental health and correlated with various physical ailments. Some preventive steps and mitigation strategies have been formed To ease and prevent physician burnout's personal and professional negative consequences. [2,3]
This article based on current scenario focuses on increased healthcare workers burnout, especially physicians and potential strategies for addressing this burden in COVID-19 time.
BURNOUT AMONG PHYSICIAN'S DURING COVID-19: GLOBAL TRENDS
A recent Medscape survey on 7500 physicians of 8 countries states that the COVID-19 had caused a profound effect on their personal and professional lives. The United Kingdom had the highest percentage (55%) of physicians reporting increased stress and grief. Next were Spain and the United States (43%), France (42 %), Brazil and Mexico (34%), Portugal (32%), and Germany (25%). [4]
A 2020 Physician Burnout Survey published in Medical Economics reported that the COVID-19 pandemic had increased the feelings of burnout among 65% of physicians in the United States. The significant factors contributing to increased burnout in COVID-19 are a general feeling of helplessness (32%), shortages of personal protective equipment (30%), financial strain (50%), health and safety issue of the family (47%) and inability to care for the patient (41%). [5]
According to the Federal Medico-Biological Agency (Russia), 10% of medical staff have depression, and 40% of medical staff have problems coping with stress. Research published in the JAMA Network had reported that about 1,257 medics in 34 hospitals in China have symptoms of depression, anxiety and sleeplessness, which has increased risk of clinical errors to 62% among depressed doctors. [6]
Another questionnaire-based survey conducted in India determined a significant prevalence of burnout during the COVID-19 pandemic among health care workers, particularly doctors and support staff, with female respondents having higher prevalence. [7]
POTENTIAL SIGNS OF BURNOUT
Burnout was first described in the mid-1970s, by Freudenberger and Maslach. It is not a new concept, but this pandemic has accelerated the negative repercussions of uncertainty and inadequate support. It is defined as ''a state of physical, emotional, and mental exhaustion resulting from long-term involvement in work situations''.
It is a multidimensional syndrome showing signs of depersonalization, cynicism, emotional exhaustion, and low personal accomplishment. Other warning signs for physician burnout are described below in Fig. 1 [8]:
POTENTIAL FACTORS CONTRIBUTING TO PHYSICIAN BURNOUT DURING COVID-19 PANDEMIC
A variety of factors can contribute to the increased burnout among health care workers during COVID-19 pandemic. Still, the clinical evidence for proven factors contributing to burnout during COVID-19 times is lacking. Some aspects which are derived from the existing knowledge of physician burnout amidst pandemic to guide best in providing support for health care professionals during these unprecedented times are explained below:
Occupational Factors
Various studies have focused on assessing the occupational factors associated with increased burnout in pandemic times. It is reported that physicians working in the front line wards are less prone to burden and burnout compared to those working in the usual wards. Also, the physicians who are more exposed to COVID-19 patients showed a higher incidence of burnout than those who were not exposed.
Gender Differences
The studies related to gender differences in COVID-19 times has demonstrated contrasting results. Some studies showed no gender differences in experiencing burnout; however, some studies indicated that female patients suffer more burnout than male healthcare workers. Increased burnout rates among females and unmarried trainees can be due to various factors such as childcare and work-life balance. It was also found that women who had young children to look after and those with a supporting spouse or family member reported decreased burnout and burden.
Increased number of working hours
The COVID-19 has worsened with time. Health care workers are spending a lot of time close to the patient. Higher the time close to the patient more the risk activities. Excess workload, working for long hours without breaks have obstructed the physical resilience and resting hours. It has caused a profound effect on concentration and personal well-being.
Sleep Deprivation
Sleep deprivation is another significant risk factor contributing to physician burnout in pandemic times, attributed to long working hours and high workload. A recent study conducted before pandemic showed that 33% of health respondents were screened positive for one of the sleeping disorders among 959 healthcare employees.
Access to basic needs
COVID-19 lockdowns have caused difficulty in accessing primary and health care needs. Lately, physicians working in these threatening conditions were worried about testing kits, PPE kits, having enough critical care staff and daycare for their children. These factors contributed to increased stress levels and burnout in physicians and health care workers.
Anxiety over a second surge
Health care workers have become used to the physical toll of working long shifts in sweaty PPEs and boosting the morale of patients and families, but the emotional toll of never-ending cases is much more than just physical exhaustion. Shortage of resources and race for an effective vaccine has affected healthcare workers' mental well-being. Various anecdotal evidence is suggesting the increased levels of anxiety, depression and psychological stress in physicians. The deteriorating mental health is contributing to increased burnout.
Experience of crisis fatigue
The physicians and health care workers are experiencing a bit of crisis fatigue now. The health care workers are tired of thinking about how to do things differently to cope with emerging difficulties and trends, combined with their families' safety concerns. All these things contribute to physical as well as mental stress among physicians.
Safety in the workplace
Physicians and health care workers are directly exposed to infected patients, thereby, are at greater risk of getting infected. Extreme long-lasting stressors and safety concerns in the work environment adversely affect healthcare workers' efficiency and cause increased burnout among these individuals. [9,10]
CONSEQUENCES OF PHYSICIAN BURNOUT
Physician burnout causes a negative impact. Various studies have postulated the negative consequences of physician burnout. A study published in the Journal Behavioral Sciences has provided detailed implications of physician burnout after reviewing the literature published in peer-reviewed scientific journals. [11] (Table.1)
Another study published in 'Mayo Clinical Proceedings' and 'Cureus' has described the various personal and professional consequences of burnout are described below in Fig. 2 [2, 12]:
POTENTIAL STRATEGIES FOR REDUCING BURNOUT IN HEALTHCARE PROVIDERS DURING COVID-19
Drastically increasing stressors on healthcare providers both during work and outside work has increased the need for preventive measures to reduce these stressors. Below are some potential strategies that would be beneficial in reducing physician burnout in pandemic times:
Strategy 1: Making healthcare providers aware of potential burnout
Burnout can be prevented by making physicians and health care aware of the risks and preparatory measures for risk reduction at the workplace. The awareness can also help to reduce complications related to burnout. For instance, a study conducted on Ebola response determined that situational awareness and other preventive strategies were beneficial in improving psychological resilience among healthcare providers. There is a need to acknowledge the concerns and adopt measures to empower healthcare during the pandemic.
Strategy 2: Promoting positive mental health: Mindfulness and self-care practices
Positive mental health should be promoted in health care workers and providers to reduce work-related stress and burnout. Various strategies such as improving work schedules, including self-care practices, decreasing the workload, promoting self-management, initiating mental health promotion activities can help reduce the burnout risk. Mindfulness-based interventions and self-management practices can help promote mental health and coping mental stress associated with increased burnout levels during COVID-19.
Strategy 3: Ensuring the availability of mental health services
The availability of mental health services is difficult during COVID-19, but exploring these opportunities can be useful. Improved access to medical health services can be provided by including mental health experts in multidisciplinary COVID-19 teams, which may diagnose burnout and refer healthcare workers showing burnout symptoms to appropriate resources. Also, peer-support sessions and group-based counselling can address burnout and improve mental health in pandemic times.
Strategy 4: Leveraging digital technologies to prevent burnout
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Strategy 5: Creating an enabling environment through organizational approaches
There is a need to improve organizational measures to create an effective work environment free of mental stress. Improving workflow management, organizing services for reducing workload, enhancing communication skills, arranging discussion for exchange of opinions, facilities for adequate rest and exercise, and formation of policies can help reduce burnout and burden among health care workers during a pandemic. These approaches also help to foster a healthy environment for physicians.
Strategy 6: Seeking professional support to cope with moral distress and grief
The unprecedented circumstances and decisions regarding the treatment of COVID-19 cause intense moral injury and distress to health care workers. Signs of moral distress include self-criticism and excessive feelings of shame, guilt and regret. Additional support is required to address the harmful effects associated with moral distress among health care workers. Seeking peer or supervisory support can help to cope with the trauma and moral distress. Your health insurance provider can also refer to mental health professionals who provide video and audio teletherapy, which is the most suitable approach during the pandemic.
Strategy 7: Supporting communication from leaders
Supportive communications regarding critical decisions from organizational leaders will help maintain personal well being and resilience among health care workers throughout the pandemic. Leaders should provide sufficient resources, PPE kits, clarify work hours, and must communicate current best practices clearly among the companions. They should also monitor clinicians' wellness and address concerns related to the safety of physicians and their families.
Strategy 8: Reducing noncritical work activities
Decreasing the burden of noncritical work activities may help in promoting mental well-being. It includes rescheduling routine patient follow-up and reducing nonessential administrative tasks. A central source should be established to update information and communicate well-defined protocols, expectations, and resources. There should be a redistribution of work and clinicians participation should be supported in computer- and phone-based care, when he/she cannot be present in the clinical settings because of mandatory isolation.
Supportive work culture is essential to maintain the resilience of clinicians during COVID-19. Developing an evidence-based menu of interventions and implementing various workplace settings can be useful. Wellness committees and employee assistance programs should be formed to organize these interventions in large hospital settings; however, a wellness champion can be appointed to achieve these goals in smaller settings. Developing back up plans to cross-train and rotate leadership is also suggested for avoiding leader burnout. [13,14]
CONCLUSION
Health care professional often experiences occupational stress leading to burnout and burden, which is aggravated during COVID-19 crisis. There is an immediate need to recognize and prevent workplace-related stress among health care workers as it adversely affects their physical, mental and emotional well being. These stressors may have profound ethical implications which significantly affects the delivery of health service and maintenance of a healthy workforce in healthcare units during the pandemic.
The preventive strategies and evidence-based approaches help identify various stressors and focus on a unique solution based on the availability of resources during these challenging times. Health policymakers and practitioners should strictly adopt these interventions and develop practices for the promotion of a healthy workplace and address ethical challenges amidst the COVID-19 pandemic.
The current scenario demands the investment of leaders and public officials for promoting the physical, emotional and mental wellness of physicians. Critical understanding and shared decision-making will help understand potential challenges faced by providers, including the potential impacts of participation or non-participation in COVID-19 responses, performance appraisal, operational challenges within and between hospital departments, individual and group psychosocial challenges affecting the health of workforce and delivery of health service during the pandemic. It is in the interest of public health to start acting in this dreadful issue rather than reacting it later when it deepens further.
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