Strategies for mitigating burnout among early career doctors in Nigeria: lessons learnt from the qualitative CHARTING study

Burnout syndrome, also called professional exhaustion syndrome, is a stress-induced disorder characterized by a state of mental, physical, or emotional exhaustion, and a reduced sense of personal accomplishment and depersonalization (Maslach et al. 1996). The World Health Organization (WHO) also defined burnout as a syndrome resulting from chronic workplace stress that has not been successfully managed. Three dimensions characterize the disorder: feelings of energy depletion or exhaustion, increased mental distance from one’s job or feelings of negativism or cynicism related to one’s job, and reduced professional efficacy.

The causes of burnout can be linked to situational factors (Bakker et al. 2014). Situational factors include job demands and resources. Job demands lead to fatigue and psychological distancing from the jobs (Bakker et al. 2014). Other factors such as ambiguity, conflict, stress, workload, and tension are among the most important ones which lead to burnout (Alarcon 2011). The medical culture is one which promotes perfectionism and “workaholic standards” with many practice settings rewarding long hours and self-neglect, whereby clinicians are stimulated to disregard themselves and deny their own needs (Adeolu et al. 2000).

Furthermore, residency training is when the bulk of early career doctors (ECDs) are engaged and practice is reputed to be challenging and demanding, placing the ECDs at the risk of burnouts (Ogundipe et al. 2018). Outcomes such as absenteeism, decreased job satisfaction, and medical errors can arise as a result of burnout (Michie and Williams 2003).

The doctor workforce is the workgroup in the health sector that is most affected by burnout. In a systematic review conducted among practicing doctors, it was found that the overall burnout prevalence among them was as high as 80.5%, with emotional exhaustion, depersonalization, and low personal accomplishment prevalence ranging from 0% to 86.2%, 0% to 89.9%, and 0% to 87.1%, respectively (Rotenstein et al. 2018). Also, a recent systematic review from Nigeria showed that the prevalence of burnout among doctors in Nigeria is between 23.6% and 51.7% (Ogunsuji et al. 2019).

In Nigeria, only limited studies have ever been conducted to explore the issues of burnout among doctors, with only very few of them conducted among ECDs. Even the limited studies just surveyed ECDs in a few selected teaching hospitals in Nigeria (Issa et al. 2009; Ogundipe et al. 2014). Interestingly, the predominant determinant found was young age, which is an attribute of ECDs (Ogunsuji et al. 2019). Furthermore, the available studies, to the best of our knowledge, were questionnaire based and would not provide the benefit derivable from a qualitative study, which provides the “how” and “why” aspects in addition to the richer dimension (Malina et al. 2011).

This study aims to qualitatively explore the views of leaders among ECDs (key informants) on (1) the causes and effects of burnout and (2) the strategies that can be adopted in mitigating burnout among ECDs in Nigeria. The reason why this study focuses on ECD leaders and delegates is because they represent other ECDs in issues pertaining to ECDs in Nigeria. Also, the adoption of qualitative research methods in this study will avail the investigators the opportunity to deeply explore the scope of the study.

The findings obtained from this study will go a very long way in informing the key stakeholders in the Nigerian health sector on how to develop appropriate interventions to improve the quality of work–life, not only that of ECDs, but also that of doctors at all levels of the healthcare system. Besides, the corrective actions taken by the stakeholders involved will be very beneficial to the quality of healthcare practice in Nigeria.

This study was a qualitative study which adopted the use of focus group discussions (FGDs) to explore information on burnout issues among a few selected ECDs in Nigeria. This study forms part of the CHARTING study, a study conducted by the members of the Research Collaboration Network (RCN) (Adebayo et al. 2019; Igbokwe et al. 2019). The RCN is a substructure of the Research & Statistics Committee (RSC). The RSC was established in the year 2018, as an ad-hoc committee, by the National Association of Resident Doctors in Nigeria (NARD), now referred to as Nigerian Association of Resident Doctors (NARD) (Adebayo et al. 2019a, b; Kanmodi et al. 2019).

It is worthy of note that the CHARTING study is the largest multidisciplinary and multicenter study on ECDs in Nigeria to date, as well as a nationally representing study to explore the psychosocial issues and other issues affecting the ECDs in Nigeria, through the use of mixed research methods (Igbokwe et al. 2019; Kanmodi et al. 2019). Other reports on multiple themes have been published from the same study. The themes explored under the CHARTING study were demographic, workplace, and psychosocial issues. This article is only reporting the psychosocial-related issues experienced by ECDs. Importantly, NARD is the oldest and largest indigenous organization of ECDs in Nigeria.

In the present study, we adopted the use of purposive sampling method for identifying the two geopolitical zones (the southwest [SW] and the south-south [SS] zones) out of six zones in Nigeria; these two geopolitical zones were selected based on the fact that they were among the top three most populous and oldest NARD communities in the country. Also, only those ECDs who were holding leadership positions under the umbrella of NARD or were delegates at the time of the study were purposively sampled for the study. The justification for focusing on these categories was that they are supposed to be more knowledgeable than others on issues concerning the challenges of ECDs in Nigeria.

Only two FGD sessions were conducted with a total of 14 respondents participating. The FGDs were limited to only two sessions because saturation of the information needed to answer the study objectives was reached. Also, the first FGD was conducted during one of the 2019 regional caucus meetings of NARD, while the second FGD was conducted during one of the Ordinary General Meetings (OGMs) of NARD in the same year (Adebayo et al. 2019). Two trained facilitators (OA and IA) coordinated the sessions, which lasted between 60 and 90 minutes. The FGDs were audio-recorded using Sony ICD-PX470 Digital Voice Recorder, and notes of essential incidents during the sessions were also made.

The voice-recorded discussions were transcribed verbatim after each session. The transcription was done concurrently with data collection, so that new ideas were explored further during the second FGD. The transcript was checked for errors, after which the data analysis software, Nvivo version 12, was used to organize the data. The initial codes were generated, and this involved listing of similar ideas from the data. After generating the codes (coding process), a repeated pattern from the codes was systematically identified across the dataset and grouped. Themes were developed by reading and rereading the coded nodes on NVivo to identify significant patterns of the themes. Subsequently, all the codes were sorted into potential themes and an initial thematic map created. The main theme and subtheme were then written out after ascertaining that they met the objectives of the study. Data analysis was done independently by the two trained facilitators. They later compared their results and areas of discrepancies were jointly resolved along with another member of the research group.

Thematic analysis was used to organize data by gathering the sources based on the words they contained. It helped to conduct text searches through word frequency queries, group words according to synonyms and other word associations, examine themes and structure, and visualize and support findings with detailed evidence.

Following our recruitment process, only 14 key informants agreed to participate in the FGDs. Almost all (12) of the respondents (Rs) were male; eight were from centers in SW geopolitical zone of Nigeria and others were from SS zone. Three were from Federal Medical Centre Yenagoa (FMCY), and eight were senior registrars (Table 1). The respondents were anonymized as Respondent 1–8 South West (R1–R8, SW) for those from SW and R1–R6, SS for those from SS geopolitical zone.

The result of our analysis showed that burnout is a severe problem among ECDs in Nigeria. Three themes were identified in our analysis, and they are: (1) predisposing factors/causes, (2) effect, and (3) strategies for mitigating burnout issues among ECDs. These themes were presented with subthemes and supportive quotes to buttress respondents’ experiences further.

As generally observed in this study, burnout issues are majorly caused by the following subthemes: low staff strength, prolonged work hours, wrong counseling as regards area of specialization, lack of job description and specification, and abuse of power by trainers, among others. According to them:

“Burn out rate among residents in this sub-Saharan Africa, Nigeria, is higher than what you find in other climes. One of the reasons you have mentioned before we have a fewer number of residents for a larger work to be done, no timing for work, long hours”.

Dwelling on the previous findings, participants unanimously agreed that the effect of burnout issues is mainly on them as they bear the brunt solely. Below transcripts justify the assertion:

“In this country, if you are working or you are on weekend calls some people do weekend calls from Friday, and they finish Monday morning, and after Monday morning they will do one or two hours break to come back to resume the same work and finish 4 o’clock. In such a situation, the person is already emotionally wrecked, physically wrecked and how about the family”.

The participants stated that burnout issues can be mitigated through the following subthemes: use of policies that restrict long work hours, provision of free yearly medicals, workforce strengthening, round table discussions among stakeholders, involvement of psychologists in managing the emotional issues of ECDs, and ECDs’ prioritization of their health, among others. Therefore, these strategies are believed to serve as supportive measures for residents under the residency program:

“Regular round table discussion should always be made by all stakeholders”.

It is also important that resident doctors reduce burnout by utilizing some preventive measures. Another stated:

“Doctors should not see themselves as superhuman beings. When you are tired, rest. When you need to go on leave, go on leave. If you are not feeling fine, take excuse duty. My perception changed when Yar’Adua died, and the country did not stop, so if the president dies, and the country did not stop, I don’t think we should think we are superhuman beings. If I have headache and is persistent for more than 2–3 hours I will take excuse, and I will go and sort out myself” “We should make sure that there is enough incentive to stay and people should take their regular leave, have leisure’s, sometimes just free yourself from academic stress and rigours, go out with your family, hang out with friends, do whatever makes you happy and enjoy your life”.

Nigeria is a country divided into six geopolitical zones. The methodological limitation of this study was the fact that only two geopolitical zones were represented in the study. Therefore, it might be difficult to make some generalizations based on the study findings.