International Journal of

Environmental Research
and Public Health

Article
Burnout Impact of COVID-19 Pandemic on Health-Care
Professionals at Assiut University Hospitals, 2020
Shimaa A. Elghazally 1 , Atef F. Alkarn 2 , Hussein Elkhayat 3 , Ahmed K. Ibrahim 4
and Mariam Roshdy Elkhayat 1, *

1 Occupational and Environmental Medicine Department, Assiut University, Asyut 715715, Egypt;
[email protected]
2 Chest Disease Department, Faculty of Medicine, Assiut University, Asyut 715715, Egypt;
[email protected]
3 Cardiothoracic Surgery Department, Faculty of Medicine, Assiut University, Asyut 715715, Egypt;
[email protected]
4 Public Health Department, Faculty of Medicine, Assiut University, Asyut 715715, Egypt;
[email protected]
* Correspondence: [email protected]

Abstract: Background: burnout syndrome is a serious and growing problem among medical staff.
Its adverse outcomes not only affect health-care providers’ health, but also extend to their patients,
resulting in bad-quality care. The COVID-19 pandemic puts frontline health-care providers at greater
risk of psychological stress and burnout syndrome. Objectives: this study aimed to identify the levels
of burnout among health-care professionals currently working at Assiut University hospitals during



the COVID-19 pandemic. Methods: the current study adopted an online cross-sectional design using


the SurveyMonkey® website for data collection. A total of 201 physicians were included and the
Citation: Elghazally, S.A.; Alkarn, Maslach Burnout Inventory (MBI) scale was used to assess the three burnout syndrome dimensions:
A.F.; Elkhayat, H.; Ibrahim, A.K.; emotional exhaustion, depersonalization, and reduced personal accomplishment. Results: about
Elkhayat, M.R. Burnout Impact of
one-third, two-thirds, and one-quarter of the respondents had high emotional exhaustion, high
COVID-19 Pandemic on Health-Care
depersonalization, and low personal accomplishment, respectively. Younger, resident, and single
Professionals at Assiut University
physicians reported higher burnout scores. The personal accomplishment score was significantly
Hospitals, 2020. Int. J. Environ. Res.
Public Health 2021, 18, 5368. https://
higher among males. Those working more than eight hours/day and dealing with COVID-19 patients
doi.org/10.3390/ijerph18105368 had significantly higher scores. Conclusion: during the COVID-19 pandemic, a high prevalence of
burnout was recorded among physicians. Age, job title, working duration, and working hours/day
Academic Editor: Paul B. Tchounwou were significant predictors for burnout syndrome subscale results. Preventive and interventive
programs should be applied in health-care organizations during pandemics.
Received: 15 March 2021
Accepted: 8 April 2021 Keywords: burnout syndrome; Maslach Burnout Inventory; COVID-19
Published: 18 May 2021

Publisher’s Note: MDPI stays neutral

with regard to jurisdictional claims in 1. Introduction
published maps and institutional affil-
Burnout syndrome (BOS) is a common occupational and public-health problem, and
iations.
recently, its importance and rates have been rising [1]. It is defined as a state of psycholog-
ical, emotional, and physical stress that occurs due to prolonged periods of exposure to
chronic occupational stressors [2]. Moreover, workers in highly stressful jobs are at higher
risk of job burnout, such as health-care workers (HCWs) during the COVID-19 pandemic.
Copyright: © 2021 by the authors. As HCWs have to take care of infected patients, they face higher rates of infection/fatality
Licensee MDPI, Basel, Switzerland.
and the fear of transmitting the infection to their families. All of these factors lead to high
This article is an open access article
social and mental pressure on HCWs dealing with the current pandemic [3,4]. BOS has
distributed under the terms and
three dimensions: feelings of emotional exhaustion (EE) (depletion of emotional resources),
conditions of the Creative Commons
depersonalization (DP) (developing cynical attitudes about patients), and a sense of low
Attribution (CC BY) license (https://
personal accomplishment (PA) [5]. BOS was first described by Maslach et al., in 1996 [6],
creativecommons.org/licenses/by/
4.0/).
and was commonly observed in those who work with people and whose jobs are character-

Int. J. Environ. Res. Public Health 2021, 18, 5368. https://doi.org/10.3390/ijerph18105368 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2021, 18, 5368 2 of 12

ized by high levels of work-related stress. It may result from a combination of individual
risk factors and organizational stressors [7].
Moreover, working in a stressful environment may affect the emotional stability of
medical staff [8]. Thus, BOS was recognized as a serious problem which is common and
increasing among medical staff, especially those dealing with critically ill patients, i.e., they
work in a stressful environment where they have to take care of their patients, and react
physically and emotionally to each patients’ problem [9]. According to the Critical Care
Societies Collaborative (CCSC), up to 45% of critical-care physicians reported symptoms of
severe BOS [10]. Previous studies have reported high prevalence of burnout among health-
care providers; ranging from 25 to 75% worldwide [8,11]. In the Arab countries, research
showed that rates of BOS were higher among females, young, unsatisfied physicians,
those not exercising, and those who had fewer years of experience [12–14]. In Egypt, a
cross-sectional study of 168 health-care providers was carried out in Zagazig University
hospitals to assess the prevalence of BOS, which found high rates of EE (53%), DP (64.3%),
and PA (67.3%) among the studied physicians [15].
BOS has several adverse outcomes: it affects not only the psychological and physical
health of HCWs, through depression, insomnia, and gastrointestinal problems, but also
the patient, in the form of bad-quality care provided by the affected staff and low patient-
satisfaction. The negative outcomes of BOS on HCWs extend to affect the health-care
organization as it can result in higher absenteeism, poor job satisfaction, repeated turnover,
low morale in the staff, and financial losses. It is important to identify factors that contribute
to burnout, and to develop strategies for preventing and treating burnout among health-
care providers, in order to create and sustain a healthy and productive workplace [16].
The COVID-19 pandemic is an ongoing pandemic of coronavirus disease 2019 (COVID-
19) which is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It is
a highly infectious disease with a long incubation period. It was first identified in December
2019 in Wuhan, China. The World Health Organization (WHO) declared the outbreak a
public health emergency of international concern in January 2020, and a pandemic in March
2020 [17]. As of 4th of April 2021, about 130.25 million cases had been confirmed, with
2.8 million deaths attributed to COVID-19 reported globally by WHO [18]. The COVID-
19 pandemic puts frontline HCWs at great risk of psychological stress. The prevalence
of high-level stress, depressive symptoms requiring treatment, and anxiety symptoms
requiring further evaluation among HCWs were 3.7%, 11.4%, and 17.7%, respectively [19].
Approximately 10% of confirmed COVID-19 cases involved health-care providers [20].
Additionally, high levels of burnout in HCWs were reported during this pandemic.
Many factors were identified as contributing to the psychological impact of this pan-
demic on health-care providers, such as the fatal nature of COVID-19, the lack of effective
treatment, the higher rate of infection and mortality among them, being away from their
families, and social stigmatization. Additionally, many organizational factors contributed
to burnout among HCWs during this pandemic, such as longer working hours, shortage of
Personal Protective Equipment (PPE), heavy workload, extensive responsibilities, lack of
specific drugs, protocols and care for unstable patients [19,21], presence of chronic disease,
and continuous changes to the locations and tasks of doctors [22,23].
BOS was represented as an increasingly serious problem among medical staff espe-
cially during the COVID-19 pandemic and was associated with difficult working conditions
and feelings of dissatisfaction at work [4]. Most studies on BOS among physicians during
the COVID-19 pandemic were conducted in developed countries, which had fewer num-
bers of infected patients, than in developing ones such as Egypt [24–26]. The current study
aimed to assess the levels of BOS and its subscales among physicians currently working at
Assiut University hospitals and to identify the most important correlates of BOS.

2. Materials and Methods

An online cross-sectional study was conducted via the SurveyMonkey® website [27]
during the current COVID-19 pandemic to evaluate the levels of burnout among physicians
Int. J. Environ. Res. Public Health 2021, 18, x FOR PEER REVIEW 3 of 13

2.18,
Int. J. Environ. Res. Public Health 2021, Materials
5368 and Methods 3 of 12

An online cross-sectional study was conducted via the SurveyMonkey® website [27]
during the current COVID-19 pandemic to evaluate the levels of burnout among physi-
cians working
working at Assiut
at Assiut University
University hospitals.
hospitals. The study
The study was conducted
was conducted in theinperiod
the period be-
between
tween June 2020 and
June 2020 and July 2020 July 2020
Sample-size
Sample-size calculation was carried
calculation was carriedout
outusing
usingananEPI EPI info
info 20002000 statistical
statistical package
package [28].
[28].
TheThe calculation
calculation waswas based
based ononanan expectedfrequency
expected frequencyof ofburnout
burnout in in physicians
physicians dealing
dealing
with
withCOVID-19
COVID-19casescasesofof13%
13%[29]
[29]during
duringthe
theCOVID
COVID attack
attackwith
witha difference
a difference of of
5%,5%,and a
and
confidence interval of 95%. The minimum sample required was 174
a confidence interval of 95%. The minimum sample required was 174 doctors. Nearlydoctors. Nearly 600
physicians were were
600 physicians invited to participated
invited in the study,
to participated the response
in the study, rate was
the response 35%
rate (201
was doctor
35% (201
completed questionnaire). A convenience-sampling technique was applied
doctor completed questionnaire). A convenience-sampling technique was applied in in this study.
this study.

2.1.Ethical
2.1. EthicalConsideration
Consideration
Theprotocol
The protocol was reviewed
reviewedby byAssiut
AssiutUniversity ethical
University committee.
ethical committee.andand
waswas
recorded
rec-
on theon
orded clinical-trial registration
the clinical-trial websitewebsite
registration (No. NCT04363229). All participants
(No. NCT04363229). were asked
All participants wereto
sign an
asked to informed-consent document,
sign an informed-consent which was
document, clearly
which wasstated
clearlyand indicated
stated the purpose,
and indicated the
procedures,
purpose, pros, andpros,
procedures, cons and
of the study.
cons Furthermore,
of the confidentiality
study. Furthermore, and anonymity
confidentiality were
and ano-
assured with no incentives or rewards for the participants. The study followed
nymity were assured with no incentives or rewards for the participants. The study fol- Declaration
of Helsinki
lowed guidelines
Declaration [30]. guidelines [30].
of Helsinki
2.2. Data Collection Tools
2.2. Data Collection Tools
A predesigned self-fulfillment questionnaire was prepared as an online version for the
A predesigned self-fulfillment questionnaire was prepared as an online version for
assessment of the levels of burnout and its determinants among the studied population.
the assessment of the levels of burnout and its determinants among the studied popula-
The questionnaire was composed of three parts:
tion.
(a) TheSocio-demographic
questionnaire wasdata of the studied
composed of threepopulation,
parts: such as age, residence, marital
status, smoking history, and history of chronic diseases.
(a) Socio-demographic data of the studied population, such as age, residence, marital
(b) Work-related characteristics, such as job title, enrolled department, working sys-
status, smoking history, and history of chronic diseases.
tem, working hours per day, working days per week, and history of dealing with
(b) Work-related characteristics, such as job title, enrolled department, working system,
COVID-19 patients.
working hours per day, working days per week, and history of dealing with COVID-
(c) Maslach Burnout Inventory (MBI) which is universally accepted as the gold-standard
19self-reported
patients. measure due to its high reliability and validity. As the Cronbach’s α
(c) Maslach Burnout
value for Inventory
the main (MBI)
MBI scale was which is universally
0.829, the emotional accepted as subscale
exhaustion the gold-standard
was 0.887,
self-reported measure due to its high reliability and validity.
the depersonalization subscale was 0.768, and the diminished personalAs the Cronbach’s
accomplish-
αment
valuesubscale
for the main MBI scale
was 0.891 [31]. was 0.829,
It was the emotional
designed to assessexhaustion subscale was
the three components of
the BOS: emotional exhaustion (EE), depersonalization (DP), and reduced personal
accomplishment (PA). It is a 22-item questionnaire on a seven-point Likert-scale
(ranging from 0 = never to 6 = every day). Scores for each section were obtained by
Int. J. Environ. Res. Public Health 2021, 18, 5368 4 of 12

adding the numeric responses of the items which corresponded to each scale. High
scores for the first two dimensions (EE and DP) and low scores for the third dimen-
sion (PA) indicated BOS [6]. MBI scores were further used to classify participants
as having low (≤17 points), moderate (18–29 points), and high (≥30 points) levels
of EE, low (< 6 points), moderate (6–11 points), and high (≥12 points) levels of DP
and For PA low (≥40 points), moderate (39–34 points), and high (≤33 points) levels
burnout dimensions.

2.3. Procedure
Several literary works were reviewed, the questionnaire was revised by all authors,
and the MBI score was translated into Arabic by specialized translators. The link was then
launched on the SurveyMonkey® website and was sent to all of the physicians at Assiut
University via their official e-mails. This was followed by repeated reminders via e-mail,
phone call, or the WhatsApp application.

3. Results
3.1. Sociodemographic Characteristics of Enrolled Doctors
Table 1 describes the sociodemographic data of the sampled doctors. It was found that
about two-thirds were female and that 90% of the sample lived in urban areas. Moreover,
44.3% of the enrolled doctors were aged 20–30 years, 36.3% were aged 30–40 years, and
19.4% were aged more than 40 years. Noticeably, only 7% were smokers.

Table 1. Sociodemographic Characteristics of cohort Doctors.

Characteristics Frequency Percentage

Gender
Male/female 70/131 34.8%/65.2%
Age group
20-/30-/40- 89/73/39 44.3%/36.3%/19.4%
Residence
Urban/rural 180/21 89.6%/10.4%
Marital Status
Single/Married 78/123 38.8%/61.2%
Smoking History
Non-smokers/Smokers 187/14 93%/7%

3.2. Figure 1: The Distribution of the Studied Cohort According to Maslach Burnout Inventory
(MBI) Categories
The overall prevalence of BOS was 6% with a mean of 60.6 ± 26 points. For the
subscales, high EE, DP and PA scores were observed in 35.5%, 70.6% and 26.4% of the
studied sample, respectively in Figure 1.

3.3. Table 2: The Association between MBI Sub-Scores and Sociodemographic Characters of
Cohort Doctors
Regarding the relationship between MBI scores and sociodemographic characters:
significantly (p = 0.01) higher PA scores were reported by males (32.7) compared to females
(28.9). Contrarily, the results of the current study did not detect any statistical difference
between males and females regarding the mean EE and DP. Furthermore, a downward
linear trend was found in the mean EE and DP for age; the youngest age group (20–30 years)
recorded the highest mean EE and DP (28.3 and 22.9, respectively), and the oldest age group
(>40 years) recorded the lowest mean EE and DP (17.5 and 1.6, respectively). Conversely,
the youngest group (20–30 years) recorded the lowest mean PA (27.1) and the oldest age
group (>40 years) recorded the highest mean PA (36.7). These associations were statistically
significant (p < 0.001) (Table 2). Moreover, there was a statistically significant relationship
between the marital status of enrolled physicians and their MBI subscale scores: single
physicians recorded higher EE (26.6) and DP (22.8) mean scores and lower PA mean scores
Int. J. Environ. Res. Public Health 2021, 18, 5368 5 of 12

Int. J. Environ. Res. Public Health 2021, 18, x FOR PEER REVIEW 5 of 13
(27.1) than married doctors (p < 0.05). On the other hand, other factors such as residence,
smoking, and chronic disease history were not statistically associated with their MBI
subscale scores (Table 2).

Figure
Figure 1. (A): Histogram
1. (A): graph of
Histogram graph of doctors
doctors Total
Total MBI score, (B):
MBI score, (B): Bar
Bar Charts
Charts of
of aa sense
sense of
of personal
personal accomplishment (PA)
accomplishment (PA)
Categories of enrolled doctors, (C) Bar Charts of emotional exhaustion (EE) Categories of enrolled doctors, (D) Bar Charts
Categories of enrolled doctors, (C) Bar Charts of emotional exhaustion (EE) Categories of enrolled doctors, (D) Bar Charts
of depersonalization (DP)
(DP) Categories
Categories ofof enrolled
enrolled doctors.
doctors.

3.3. Table
Table 2. Distribution of doctors 2: The
Maslach Association
Burnout between
Inventory meanMBI Sub-Scores
scores accordingand Sociodemographiccharacteristics,
to sociodemographic Characters of
smoking history, and chronicCohort Doctors
disease.
Regarding the relationship between MBI scores and sociodemographic characters:
Emotional Exhaustion Depersonalization Personal Accomplishment
N (%)
significantly (p = 0.01) higher PA scores were reported by males (32.7) compared to fe-
Characteristics
(N = 201) Mean (SE) p Value * Mean (SE) p Value * Mean (SE) p Value *
males (28.9). Contrarily, the results of the current study did not detect any statistical dif-
Gender ference between males and females regarding the mean EE and DP. Furthermore, a down-
Male 70 (34.8%)
ward linear22.7trend
(1.4) was found
0.24 in the mean
19.3 (1.4)
EE and DP 0.74 32.7
for age; the (1.3)
youngest 0.01 (20–
age group
female 131 (65.2%) 24.8 (0.9) 18.1 (0.8) 28.9 (0.9)
30 years) recorded the highest mean EE and DP (28.3 and 22.9, respectively), and the old-
Age group
20- est age group
89 (44.3%) (>40 years)<0.001
28.3 (1.1) recorded the22.9lowest
(1.0) mean<0.001
EE and DP (17.5 and 1.6, respectively).
27.1 (1.2) <0.001
30- Conversely,
73 (36.3%) the youngest
22.5 (1.3) group (20–30 years)
16.7 (1.2) recorded the lowest
30.6 (1.1) PA (27.1) and the
mean
40- oldest age17.5
39 (19.4%) group
(1.6)(>40 years) recorded 1.6the highest mean PA (36.7).
(1.4) 36.7These
(1.7) associations were
Residence statistically significant (p < 0.001) (Table 2). Moreover, there was a statistically significant
Urban 180 (89.6%) 24.2 between
relationship (0.8) the0.72 18.6 (0.8)
marital status 0.65physicians
of enrolled 30.2 (0.8)their MBI0.75
and subscale
Rural 21 (10.4%) 23.1 (2.8) 17.3 (2.1) 31.2 (2.3)
scores: single physicians recorded higher EE (26.6) and DP (22.8) mean scores and lower
Marital Status
Single PA mean26.6
78 (38.8%) scores
(1.1)(27.1) than
0.01 married doctors
22.8 (1.1) (p < <0.001
0.05). On the27.1
other
(1.1)hand, other factors
0.001
Married such
123 (61.2%) as residence,
22.5 (1.1) smoking, and chronic disease
15.7 (0.9) history were not statistically
32.2 (0.9) associated
Smoking History with their MBI subscale scores (Table 2).
Non-smokers 187 (93%) 24.2 (0.8) 0.56 18.3 (0.8) 0.48 30.2 (0.8) 0.95
Smokers 14 (7%) 22.4 (2.9) 20.7 (3.1) 30.9 (2.5)
Chronic disease
Yes 31 (15.4%) 24.3 (2.2) 0.90 19.5 (2.2) 0.70 32.2 (2.1) 0.25
No 170 (84.6%) 24.1 (0.8) 18.3 (0.8) 29.8 (0.8)
* Mann Whitney test.
Int. J. Environ. Res. Public Health 2021, 18, 5368 6 of 12

3.4. Table 3: The Association between MBI Sub Scores with Their Workplace Characteristics and
History of COVID-19 Cases Exposure
Concerning job title, resident doctors showed the highest scores for EE and DP, and
lowest PA scores, followed by assistant lectures, then specialist/Lecturer, and finally,
Assistant prof/professors (p < 0.05). Oppositely, their EE and DP mean scores were not
affected by their medical subspecialty, but PA scores were recorded to be significantly
higher among doctors in Surgical/Anesthesia and ICU departments (p < 0.001) (Table 3).
Although, there were significantly higher DP scores among physicians with mixed shifts
(19.9) than among others working only morning shifts (16.5), their EE and DP mean scores
were not affected by this working system. Moreover, physicians attending work for more
than 8 h per day recorded the highest EE and DP mean scores compared to workers
working 4–8 h and <4 h (p < 0.001). Regarding histories of dealing with COVID-19 patients:
statistically, only the DP mean score was found to be significantly higher among physicians
who had a history of dealing with COVID-19 patients (21.6) when compared to physicians
who did not have a history of dealing with COVID-19 (17.1) (p = 0.01). Although the
EE score was recorded to be higher in physicians who had treated COVID-19 patients
historically than those who had not, this did not show a statistically significant difference,
while both had the same PA score (Table 3).

Table 3. Distribution of the doctors’ Maslach Burnout Inventory mean scores according to some workplace characteristics
and COVID-19 case exposure.

N (%) Emotional Exhaustion Depersonalization Personal Accomplishment

Characteristics
(N = 201) Mean (SE) p Value * Mean (SE) p Value * Mean (SE) p Value *
Job title
Resident doctor 67 (33.3%) 27.4 (1.3) 0.01 23.6 (1.3) <0.001 26.1 (1.4) <0.001
Assistant lecturer 74 (36.8%) 25.9 (1.2) 19.0 (1.1) 29.9 (1.2)
25 (12.4%) 18.7 (2.3) 12.5 (1.5) 34.5 (1.8)
Specialist/Lecturer
Assistant
35 (17.4%) 17.9 (1.6) 11.9 (1.4) 35.8 (1.8)
prof/Professors
Working specialty:
Medical 92 (45.8%) 22.9 (1.1) 0.41 17.2 (0.9) 0.37 31.9 (1.1) <0.001

Surgical/Anesthesia 59 (29.4%) 24.9 (1.6) 19.8 (1.6) 32.8 (1.5)

and ICU
Academic 50 (24.9%) 25.2 (1.5) 19.3 (1.5) 23.9 (1.5)
Direct exposure with
COVID-19 case
Yes 63 (31.3%) 26.1 (1.4) 0.08 21.6 (1.4) 0.01 30.7 (1.3) 0.78
No 23.1 (0.9) 17.1 (0.8) 30.0 (0.9)
Working system
Morning Shifts 85 (42.3%) 22.4 (1.2) 0.06 16.5 (1.2) 0.02 31.3 (1.1) 0.24
Mixed shifts 115 (57.5%) 25.4 (1.1) 19.9 (0.9) 29.4 (1.1)
Working hours
per day
<4 h 26 (12.9%) 15.8 (2.2) <0.001 11.5 (1.8) <0.001 34.6 (1.9) 0.04
4–8 h 95 (47.3%) 23.2 (1.1) 16.3 (0.9) 30.6 (1.1)
>8 h 80 (39.8%) 27.8 (1.2) 23.3 (1.1) 28.3 (1.3)
* Mann Whitney test.

3.5. Figure 2 Correlations between Working Duration and Working Days per Week with Maslach
Burnout Inventory Subfield Scores
Multicollinearity diagnosis was depicted in Figure 2. This shows a moderately sig-
nificant negative correlation of EE and DP scores of enrolled doctors with regards to their
working experience (r = −0.33, p ≤ 0.001 and r = −0.39, p ≤ 0.001, respectively). Oppo-
sitely, a significant positive mild correlation was found with their working days per week.
Int. J. Environ. Res. Public Health 2021, 18, 5368 7 of 12

Int. J. Environ. Res. Public Health 2021, Moreover, PAREVIEW

18, x FOR PEER scores of
all of the doctors recorded significant mild positive correlation
8 with
of 13
working duration only (r = 0.28 and p ≤ 0.001).

Figure
Figure 2.
2. Correlation
Correlation between
between working
working duration
duration and
and working
working days
days per
per week
week of
of physicians
physicians and
and their
their EE
EE score
score (a),
(a), DP
DP score
score
(b), and PA score (c).
(b), and PA score (c).
4. Discussion
4. Discussion
During the
During the COVID-19
COVID-19 pandemic,
pandemic, several
several studies
studies revealed
revealed aa high
high prevalence
prevalence of of stress
stress
and burnout among health-care workers [32], thus affecting their quality of
and burnout among health-care workers [32], thus affecting their quality of life as well aslife as well as
the quality of health service provided [33]. Assiut University hospital is one of
the quality of health service provided [33]. Assiut University hospital is one of the largest the largest
tertiary-level hospitals
tertiary-level hospitals in
in Egypt.
Egypt.
Thecurrent
The currentstudy
studyrevealed
revealed that
that about
about one-third
one-third (35.5%),
(35.5%), two-thirds
two-thirds (70.6%),
(70.6%), and
and one-
one-quarter (26.5%) of the respondents recorded high EE and DP, and low
quarter (26.5%) of the respondents recorded high EE and DP, and low PA, respectively. PA, respectively.
Also, 6%
Also, 6% had
had BOS
BOS (high
(high scores
scores for
for the
the first
first two
two dimensions
dimensions (EE(EE and
and DP)
DP) and
and low
low scores
scores
for the third dimension (PA)). This was consistent with a multinational study
for the third dimension (PA)). This was consistent with a multinational study carried out carried out
in 45 countries to explore the prevalence of BOS among health-care professionals
in 45 countries to explore the prevalence of BOS among health-care professionals during during
thefirst
the firstwave
waveofofthe
the COVID-19
COVID-19 pandemic.
pandemic. It was
It was foundfound that about
that about half of
half (56%) (56%) of the
the cohort
cohort showed high EE, 48.9% recorded high depersonalization, and
showed high EE, 48.9% recorded high depersonalization, and about one-third (38%)about one-third (38%)
showed low PA [34].
showed low PA [34].
Across the world, burnout prevalence was lower than that reported in this research:
Australia (30%) [35], Brazil (21%) [36], Wuhan (FL 13% vs. UW 39%) [29], Italy (37%, 25%,
Int. J. Environ. Res. Public Health 2021, 18, 5368 8 of 12

Across the world, burnout prevalence was lower than that reported in this research:
Australia (30%) [35], Brazil (21%) [36], Wuhan (FL 13% vs. UW 39%) [29], Italy (37%,
25%, 15.3%) [37] and Spain (41%, 15.2%, 8.4%) [33]. Unlikely, the prevalence was higher
in Portuguese HCWs (53%) [38,39]. This diversity of results could be attributed to the
different scales used, cultural differences, and dissimilar health systems.
Concerning gender effect on BOS: statistically, PA scores were significantly higher
among males than females (p = 0.01), while EE and PD scores were not affected by gender.
This matched with a study in New Zealand [39]. Other studies recorded no difference [31],
thus indicating that females were more liable to burnout than males. This could be ex-
plained by their loads of household work which, in addition to their career responsibilities,
could raise stress [40]. On the other hand, other studies reported that more females were
liable to experience EE [41,42].
In the current work, age was found to be a significant factor affecting MBI score, as
the youngest age group (20 < 30) recorded the highest EE and DP, and the lowest PA scores
(p < 0.001). In agreement with these findings, an Indian study was carried out during
the COVID-19 pandemic among HCWs [43], finding that burnout was higher among the
younger population. This finding was supported by previous studies conducted before
the pandemic attack in different areas [44–46]. This could be attributed to the workload
and lack of working experience at the beginning of their careers; additionally, juniors have
more contact on the frontline with COVID-19 patients than senior HCWs [47]. On the other
hand, Salem et al., 2018, were not consistent with our results as they found that there was
no significant relationship between age and burnout, and reported that increasing age
significantly increased the perception of EE (β = 0.247, p = 0.019), while it had no significant
impact on DP or PA (p > 0.05) [48].
Concerning marital condition, single doctors were more liable to burn out than married
doctors as they had significantly higher EE and DP scores and lower PA scores. Our results
matched with a multicentric Egyptian study on medical oncology professionals which
reported that being married was significantly associated with higher levels of personal
accomplishment; this may be due to the support given by a partner. Conversely, single
women can be put under great work and social stress by our Middle Eastern society [49].
The current results were comparable to those of the New Zealand national survey in which
being single was associated with higher levels of EE [39]. Likewise, it was in accordance
with a cross-sectional study among HCWs in Aswan University Hospital [31]. On the other
hand, studies conducted in Saudi Arabia [45] and Egypt [50] concluded that higher BOS
levels were strongly associated with married respondents.
The current study revealed that resident doctors had the highest scores for EE and DP,
and the lowest PA scores. This was supported by the moderate negative correlation found
between working experience years and both EE and DP scores of the enrolled doctors,
and by the mild positive correlation between PA score and number of working experience
years. These findings were consistent with a study conducted in Pakistan which reported
higher DP scores in doctors with less than 10 years’ experience and higher PA scores among
older doctors [51]. In 2013, a study of physicians in a tertiary hospital in Saudi Arabia
concluded that the physicians who were most affected by burnout syndrome were resident
physicians [45,52].
Furthermore, a systematic review of studies on BOS prevalence among health-care
professionals (HCP) in the Arab countries, according to the Preferred Reporting Items for
Systematic reviews and Meta-Analyses (PRISMA) guidelines [53] reported high levels of
burnout, with the highest prevalence in the EE and DP and lowest PA among resident
doctors. This may be explained by the high workload placed upon them, long working
hours, and low salary. Additionally, experienced senior doctors become more skilled and
committed to their work; therefore, they may be calmer and more capable of facing and
managing occupational stressors. They may feel more successful in their profession, thus
the lower levels of, and greater adaption to, burnout among them [54,55]. Compared to
other Egyptian studies, no significant association between years’ of work and burnout
Int. J. Environ. Res. Public Health 2021, 18, 5368 9 of 12

occurrence was reported by Abdallah, 2019 [15], and a significant positive correlation
between burnout subscales and years’ of work were reported by Abd EL Latief [56]. The
medical department staff were the first line of defense against COVID-19 and academic
department staff were overloaded with online learning. However, most unnecessary
surgeries were postponed during the attack, thus keeping the workloads of surgical staff
lower during the attack than those of others. Statistically, doctors with mixed shifts had
significantly higher DP scores than doctors with only morning shifts. This was consistent
with a French study [57] which reported that increased frequency of night shifts/month
were associated with increased risk of burnout. Our findings also matched the results of a
systematic review of studies on BOS prevalence among Arab HCPs that concluded that
DP was higher among nurses who worked night shifts and rotating shifts [58]. Moreover,
a Lebanese study [59,60] reported that DP scores were higher among nurses who work
night shifts and rotating shifts compared to daytime workers. This study revealed that
working more than 8 h per day was associated with higher EE and DP scores than working
4–8 h and <4 h. The finding of the current research was similar to two studies conducted in
Yemen, 2009 [59], and Lebanon, 2010 [46], which reported a significant association between
burnout and long working hours per week. Another study, conducted upon USA military
treatment facilities, reported that working more hours was independently predictive of
higher burnout scores [41].
Additionally, doctors dealing with COVID-19 patients had higher EE and DP scores,
but the difference was only statistically significant for DP as this was one of four significant
predictors for DP (dealing with COVID-19 patients increased the DP scores by three points).
The current findings matched a study conducted in China during the COVID-19 pandemic
that found high prevalence of burnout among frontline nurses [60]. Prior to this pandemic,
HCWs were already exposed to burnout risk. This pandemic has exacerbated existing risks
and triggered new risks as it led to a sharp increase in admissions of critically ill COVID-19
patients to hospitals, which led to an increase in the workload of HCWs. Additioally, HCWs
faced risk of exposure to the COVID-19 infection, long working hours, critical decision
making, fatigue, and the fear of spreading the infection to family members. All of this leads
to more psychological distress and higher levels of burnout faced by frontline health-care
providers [38].
Strengths and Limitations:
This study has encountered several limitations: firstly, the cross-sectional nature lacks
causal effect and might jeopardize its external validity; secondly, the online survey method
of data collection, which limits the sample to social media-active people (resulting in a low
representation of those aged >40 years, whose response was less than younger respondents)
might have led to selection bias; thirdly, sample selection was obtained via a convenience-
based non-probability technique which may result in lack of representation of all medical
classes and limit its generalizability.

5. Conclusions
The findings of this study offered an early insight into the serious problems facing
physicians who currently work at Assiut University hospitals, especially during the COVID-
19 pandemic, which might affect them in negative way. This study provides some guidance
for possible interventions. About one-third, two-thirds, and one-quarter of the respondents
had high EE, DP, and low PA, respectively. Younger, resident, and single physicians
reported higher burnout scores. Personal accomplishment scores were significantly higher
among males. Those working more than eight hours/day and those dealing with COVID-
19 patients had significantly higher scores. Likewise, age, job title, working duration,
and working hours/day were significant predictors for BOS subscale. Preventive and
interventive programs should be applied in health-care organizations during pandemics.
Int. J. Environ. Res. Public Health 2021, 18, 5368 10 of 12

6. Recommendations
Burn out is one of the most important problems facing health-care physicians, espe-
cially during pandemic status (i.e., COVID-19). Hence, all hospitals should prioritize the
planning and implementations of strategies to face the situation and support doctors, such
as psychological clinics and hotline systems for HCWs, especially physicians. Improve-
ments to work ergonomics and environment (e.g., provide more physicians on each shift,
if possible, to decrease workload and assist the occupational health clinic in protecting
HCWs) should be enforced by legislations.

Author Contributions: Formal analysis, S.A.E., A.K.I. and M.R.E.; investigation, S.A.E., A.K.I. and
M.R.E.; resources, S.A.E., A.K.I., A.F.A. and M.R.E.; data curation, S.A.E., A.K.I. and M.R.E.; writing—
original draft preparation, S.A.E. and M.R.E.; writing—review and editing, A.K.I.; visualization, H.E.
and A.F.A.; supervision, A.K.I.; project administration, S.A.E. and M.R.E.; funding acquisition, None.
All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: The study was conducted according to the guidelines of the
Declaration of Helsinki and approved by clinical-trial registration website (No. NCT04363229) and
Assiut University ethical committee.
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: Data is available upon request for ethical purposes.
Acknowledgments: This paper has been written in the context of the research project “psychological
impact of COVID-19 among doctors in Assiut University”; thus, we acknowledge the Faculty of
Medicine, Assiut University. The authors would like to thank all the physicians of Assiut University
hospitals participated in this study.
Conflicts of Interest: The authors declare no conflict of interest.

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