key: cord-0859327-67klolcy authors: Nurikhwan, Pandji Winata; Felaza, Estivana; Soemantri, Diantha title: Burnout and quality of life of medical residents: a mixed-method study date: 2022-03-01 journal: Korean J Med Educ DOI: 10.3946/kjme.2022.217 sha: d08619273243340cc2330035a7f267ca6c7c3b6e doc_id: 859327 cord_uid: 67klolcy PURPOSE: Currently there are a limited number of comprehensive studies exploring in more depth the relationship between burnout and quality of life (QoL) of medical residents during residency training. This study aims to examine the correlation between burnout and residents’ QoL and explore the factors associated with burnout in residency training. METHODS: This was a mixed-method study. The first stage was a quantitative study using cross-sectional design to administer the Maslach Burnout Inventory Human Service Survey and World Health Organization Quality of Life-BREF instruments to 86 medical residents, followed with the qualitative study through 10 in-depth interviews. RESULTS: Twenty-seven residents (31.4%) experienced severe emotional exhaustion (EE), 22 (25.6%) experienced severe depersonalization (DP), and 40 (46,5%) experienced low personal accomplishment (PA). Factors increasing the likelihood of experiencing burnout were being surgical residents for EE (2.65 times), dealing with difficult/rare cases for DP (1.14 points), and working hours for PA (1.03 points). The QoL was influenced by the three burnout domains, marital status, education level, gender, age, type of residency, night shift, difficult/rare cases, working hours, and number of emergency cases. Factors influencing burnout, both intrinsic and extrinsic, were identified and divided into causative and protective factors. CONCLUSION: The current study has examined the relationship between burnout and QoL and identified factors affecting residents’ burnout. Both intrinsic factors, such as spirituality, and extrinsic factors which include duration of shift, work facilities, and teacher-senior-junior relationships, affect burnout. Supervision and academic regulation are some of the solutions expected by the residents to minimize burnout. Burnout is a state describing a response to chronic work-related stress, and consists of three dimensions, emotional exhaustion (EE), depersonalization (DP), and decreased perceptions of personal accomplishment (PA) [1, 2] . This state was discovered to be at a higher rate among medical residents (39% to 85%) compared to medical students (28% to 45%) [3, 4] . The factors influencing burnout are classified as either intrinsic, comprising demographic characteristics (gender and age), social conditions, psychological conditions, and individual characteristics, or extrinsic, including work environment and organizational factors [5] . Residency program is a postgraduate medical edu-cation and an in-depth mastery training of certain field (specialty) of medical specialties, with independent learning methods as well as supervision. Residents undergo learning processes in teaching hospitals through providing specialized health services to patients, and this often causes significant stress levels, resulting in burnout. Residents with burnout tend to experience barriers while working, personal health and well-being deterioration, obstacles in building social relationships, difficulties in determining diagnoses (diagnostic dilemma), as well as experiencing difficulties in their ability to provide optimal patient care and to perform academically [1] . Quality of life (QoL) is a multidimensional standard level consisting of individual or community expectations for a good life [6] . A decrease in life quality tends to occur in residents with burnout, and this possibly leads to depression, risk of medical errors, and jeopardizes patient safety through misdiagnosis and errors in therapy [1] . The Maslach Burnout Inventory (MBI) remains a suitable instrument for measuring burnout. Based on the meta-analysis results, MBI has high reliability in all three domains, high test-retest reliability, and the ability to assess community service-related works. This instrument also has several variations depending on their context of which they were utilized. MBI focusing on assessing work in community services is called the Maslach Burnout Inventory Human Service Survey (MBI-HSS) [7] . The instruments to measure QoL can be divided into general and specific instruments. General instruments are used to measure the QoL in general, including functional abilities, disabilities, as well as concern about getting sick. Some of the most frequently used instruments include the World Health Organization Quality of Life (WHOQOL)-BREF, Short Form-36, and EuroQOL-5 Dimension [6] . Meanwhile, specific in-struments are used to measure specific aspects of disease (e.g., QoL Questionnaire in Schizophrenia), certain populations (e.g., in the elderly), or special functions (e.g., emotional functions) [8] . Currently, studies exploring the measurement of QoL and its relationship with burnout among residents is very limited [9] [10] [11] , and has not been linked to other factors, such as length of working experience, phase of study, and number of cases encountered. This study therefore aims to examine this relationship and explore the factors associated with burnout in residency training. The findings from this study are expected to serve as a basis for formulating burnout prevention and management program in residency program. The study was conducted in six residency programs of one public medical school in Indonesia from January to July 2020. Residency program in Indonesia is universitybased. The length of study varies depending on each residency field, but in average it takes 7-11 semesters to complete the program. As doctors in training, residents are assigned with certain clinical responsibilities either in outpatient or inpatient settings, under consultant supervision, according to their phase of study. Residents must pay tuition fee each semester and clinical teaching and learning process is conducted by a team of clinical teachers from each department. The rights and obligations of residents are determined together by the faculty of medicine and teaching hospital. This study used a mixed-method design carried out in two stages to obtain comprehensive understanding of burnout in residency program. The first was a quantitative study, with a cross-sectional design, using the MBI-HSS and WHOQOL-BREF instruments, to identify the level of burnout and QoL of residents. Qualitative design was used in the second stage through in-depth interviews to explore the factors associated with residents' burnout. Six residency programs were selected based on the representation of surgical (surgery, obstetric and gynecology, anaesthesiology) and non-surgical disciplines (internal medicine, pulmonology, paediatric). These six programs have also represented the larger department in the hospital (surgery, obstetric and gynecology, internal medicine, and paediatric) and the smaller ones (anaesthesiology and pulmonology). The study participants for the first stage were 86 medical residents from six residency programs of one public medical school in Indonesia. The number of sample was deemed sufficient based on the sample calculation formula for cross sectional study [12] . In stage two, 10 resident participants were purposively selected using a maximum variation sampling strategy by sampling participants from each group of gender (male/female), marital status (married/not married), phase of study (semester 1-2/ semester 3 and above), and burnout level (low, moderate, high). This purposive sampling was intended to obtain complete perspectives regarding factors associated with burnout from respondents with different background. Data collection in the first stage was conducted using two online questionnaires, MBI-HSS and WHOQOL-BREF. In addition to that, participants' demographic data were also obtained, such as age, gender, type of residency program and marital status, the number of working hour and night shifts per week, number of emergency/death cases, and difficult/rare cases per week (Table 1) Descriptive analysis using IBM SPSS ver. 23.0 (IBM Corp., Armonk, USA) was applied to the data of gender, type of residency program, marital status, phase of study, the number of working hour/night shifts, and the number of death and difficult cases. Burnout score and WHOQOL-BREF scores were also calculated. The burnout scores were distributed into the three subscales (domains) within the MBI-HSS, which were EE, DP, and PA. Each item in the subscale was measured using a 7-point Likert scale and the scores of the subscales were grouped based on the cut-off score for each category of low, moderate, and severe/high according to Maslach et al. [7] . A multivariate analysis using linear regression test (for QoL variable) and logistic regression test (for burnout variable) was also carried out to examine the relationship between the demographic variable with burnout and QoL. Data are presented as number (%), mean±standard deviation, or median (min-max). a) Data are normally distributed. conclusions drawing and verification, including member checking, followed the process [13] . This study received ethical clearance from the Universitas Lambung Mangkurat (No.060/KEPK-FK UNLAM/EC/II/2020). Table 3 shows the characteristics of 10 residents involved in the in-depth interviews. Based on the thematic analysis, intrinsic and extrinsic factors in- How to read the fluencing burnout were identified. Each of these factors was further divided into burnout causative and protective factors (Fig. 1) . The burnout impact and the institutional support system in protecting burnout among residents were also identified. Burnout causative factors are factors within the individuals that influence the occurrence of burnout. Several of these factors identified in this study include Respondents also mentioned that spirituality helps in overcoming problems during study. to stand by at the ward, now we had to also stand by at the emergency room." (RESP-1) "Limited materials when treating wounds, such as the unavailability of gauze, has made us run again to a place providing it. This is also a factor of burnout." (RESP-6) The external factors protecting burnout include support from peer and family and also the institutional support system. "To prevent burnout, we can ask friends for help because the surgery program teaches teamwork. We have made a commitment to help other friends if there is a problem." (RESP-6) "In obstetric gynecology department, there is a team, if someone is having burnout, his/her friend or senior automatically has to back him up. We were very trained from the first semester to be able to cope and solve problems." (RESP-3) Burnout had negative impacts on both the physical and psychological state of the residents and also their work and academic performance. Some residents mentioned the lack of focus which often caused self-endangering. Meanwhile, performance-related impacts include suboptimal healthcare service, missed schedules and academic targets, and increased dropout rate. "Resident burnout is dangerous. For example, lack of focus during injection administration may cause harm, or when he comes home from work with unfocused and conscious mind, may prone to accidents." (RESP-2) "The common health problem during burnout is to become sick more often. Burnout may even create self-harming thoughts such as injuring yourself or having thoughts of suicide." (RESP-9) According to the study participants, the institutional support system is the factor expected to prevent or minimize burnout. The institutional support system includes academic regulation, supervision, psychological support, burnout screening, and leisure activities. Some respondents mentioned the need for the institution to regulate the residents' working hour. The participants also expect the institution to provide professional psychological support provided by psychologists for the problems experienced by the residents. This study demonstrated burnout incidents in residency program in one teaching hospital in Indonesia in which 32.6% residents had a high level of burnout in at least one aspect of PA, DP, or EE. These results are in line with the study by Zis et al. [14] in Greece that showed 134 of 290 residents (51%) experienced a high level of burnout in at least one aspect of PA, DP, or EE, [19] stated that poor QoL is strongly associated with burnout, reduced work performance and early retirement. Burnout and QoL are likely to be influenced by numerous factors [19] . The current study has identified both intrinsic and extrinsic factors which either can cause or protect residents from burnout. The intrinsic causative factors include physical exhaustion, personality, motivational and time management. Previous studies stated that individuals experiencing physical exhaustion also report sleep disturbances. This shows that sleep disturbance may be more associated with an exhaustion component of burnout [14] . Good state of physical health may be difficult to be achieved by residents who work more than 80 hours per week since residency program is associated with chronic lack of sleep [20] . The residency program needs to be of the residents' own choice and in line with the field of interest, because otherwise, the individual experiences a sense of compulsion to undergo all activies, resulting in burnout and decreased QoL. This is consistent with the findings of Malik et al. [21] , stating the incidence of burnout is closely correlated with unhappiness with one's profession, as well as a desire for a profession change. In terms of time management, residents experiencing burnout tend to complete tasks under suboptimal conditions and in a hasty manner. This is also reinforced by the findings from other studies showing that handover of assignments between residents is often carried out in less-than-optimal conditions, including within public places, often being interrupted, and without giving the recipients an opportunity to ask questions [17] . Intrinsically, protective factors include personality, coping stress, adequate rest, and spirituality. This is in accordance with the report from Dimitriu et al. [22] showing that optimism, high motivation, and extrovert personality are able to reduce personal anxiety and consequently prevent burnout. Spirituality is also identified as one of the inhibiting factors for burnout. Wachholtz and Rogoff [23] discovered that individuals with higher spirituality scores were less likely to experience severe burnout or depression. Individuals with high spirituality tend to describe a feeling of satisfaction with life in general [23] . A study by Estupiñan and Kibble [24] showed a significant inverse correlation between spirituality level and burnout incidence as well as between spirituality and cynicism. Thus, spirituality is a possible means of functional coping, through the search for meaning, purpose and hope in life, and able to replace cynicism as a coping mechanism, during burnout. However, no studies were found regarding the relationship between spirituality and burnout in the context of medical residents [24] . Several factors, namely institutional support system, peer support, and family support, are identified as extrinsic protective factor. According to Rogers et al. [28] , in the workplace, medical colleagues are a potential source of support, in addition to family and friends. The study identified co-workers as a significant form of support for relieving work-related stress and burnout [28] . Participants also stated the importance of counseling facilities for preventing burnout. This is in line with the study of Fainberg and Lee [25] which showed that institutional factors, for example, access to psychological health services and formal counseling, are correlated with lower burnout rates. Putri et al. [29] provided suggestions for the institution to ensure residents have regular and reliable access to family doctors, psychologists, as well as psychiatrists. The current study has examined the relationships between burnout and QoL of residents. This implies that to obtain a high QoL, burnout needs to be minimized. Moreover, this study has identified the negative impact of burnout, which are underperformance and physical and psychological disorders. Therefore, it is essential for the institution to support residents through screening for burnout from the early stage, even at the admission, provision of support system and adequate infrastructure, No potential conflict of interest relevant to this article was reported. Author contributions: All authors designed the study. PWN led the data collection and analysis. EF and DS involved in the data analysis and interpretation. PWN drafted the manuscript, EF and DS were involved in the significant revision of the manuscript. All authors approved the final version of the manuscript. 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