Introduction
Worldwide, emergency department (ED) patient and disease burden is expected to increase over time, escalating the growing demand for healthcare workers (HCWs). In South Africa these challenges are compounded by a lack of resources and lower staff-to-patient ratios compared to developed countries.(1)
The increased workload, overcrowding, staff shortages and resource constraints in the ED, can lead to work-related stress, dissatisfaction and a higher staff turnover.(2–4) This creates additional costs for recruitment, training and employing temporary staff, thus negatively impacting patient outcome and satisfaction.(4)
The South African research priorities for 2021–2024 include the need for research on HCW dissatisfaction, burnout, and the retention of staff.(5) The aim of this research was to determine the levels of burnout, job satisfaction, and the intention to leave among ED HCWs and to explore the reasons for employee resignation.
Methods
This study was a prospective observational cross-sectional study conducted in the medical EDs of 2 tertiary hospitals: Chris Hani Baragwaneth Academic Hospital (CHBAH) and Charlotte Maxeke Johannesburg Academic Hospital (CMJAH). The inclusion criterion was full-time employment as a nurse or medical doctor over a 4 month period (24 November 2020 to 24 March 2021). The participants were invited to complete an anonymous, self-administered paper-based questionnaire. (Supplementary Figure 1) The study was approved by the Human Research Ethics Committee (Medical) of the University of the Witwatersrand. The Copenhagen Burnout Inventory was chosen because of its accuracy in patient-based occupations.(6) The job satisfaction survey published by Delobelle et al was included.(7) Additionally, participants were asked to name 3 components they enjoyed most and least about their work. The questions published by Scanlon et al were used to determine intention to leave (8) and respondents indicated when, where and why they wanted to leave. Lastly, the effect of violence, infection-risk and the Covid-19 pandemic was assessed using a Likert scale.
After collecting data using Microsoft Excel™, statistical analyses were conducted in R software (version 4.00; www.R-project.org). The data sets were tested for normality using the Shapiro–Wilk test and examined using Q-Q plots. Burnout, job satisfaction and intention to leave scores deviated from normality and were analyzed using general linear models. The correlation between burnout, job satisfaction, intention to leave and other factors were analysed using Spearman correlations. Tests were two-tailed and model significance set at 0.05.
Results
A total of 78 respondents in the two ED units completed questionnaires and were included for analysis. These included 66% of all medical doctors, 19 from each unit, and 58% of all nurses, CHBAH 21 and CMJAH 19.
Severe burnout was present in 76% of staff for personal burnout (CHBAH doctors 79% and nurses 62%, CMJAH doctors 79% and nurses 84%), 73% for work-related burnout (CHBAH doctors 68% and nurses 62%, CMJAH doctors 95% and nurses 68%), and 36% for patient related burnout (CHBAH doctors 42% and nurses 24%, CMJAH doctors 47% and nurses 32%). Doctors had significantly higher patient-related burnout scores (p<0.012).
Job satisfaction was average for all staff, but nurses were significantly less satisfied (p<0.003). Doctors were more satisfied because of a significantly higher pay score (p<0.001) and training score (p<0.001).
Nurses had a higher intention to leave score than doctors, especially CMJAH nurses (p<0.046). The percentage of staff who answered ‘yes’ to any of the intention to leave questions was higher for nurses and higher for CMJAH staff.
Only 16% of CMJAH staff members did not want to leave within the next 5 years, compared to 37% of CHBAH staff members. CMJAH staff indicated that 45% wanted to leave within a year (including 42% as soon as possible) and 39% within 2 to 5 years (CHBAH 40% within the year, 15% as soon as possible, 23% within 2–5 years). A total of 73% of staff wanted to leave in the next 5 years. The main reasons given for intention to leave were career-related. (Figure 1)
The Spearman correlation between intention to leave and job satisfaction showed a significant negative relationship. (Spearman rho = -0.52, p < 0.001) There was a significant positive relationship between intention to leave and burnout. (Spearman rho = 0.54, p < 0.001) (Figure 2)
HCWs were more likely to answer ‘yes’ to all intention to leave questions if they had lower job satisfaction scores in the categories of supervision, training and co-worker relationships, or higher scores for personal and work-related burnout, or if they were negatively affected by violence.
‘I am actively looking for a job’ showed a statistical significance with place of work (CMJAH p<0.04) and time in current ED (11–15 years in current ED p<0.001)
‘As soon as I find another job I will leave’ showed a statistical significance for job type (nurse p<0.001), place of work (CMJAH p<0.04), gender (female p<0.03), time in any ED (11–15 years p<0.03) and time in current ED (11–15 years p<0.03).
Discussion
The burnout scores and the percentage of staff with severe burnout were higher than similar populations before and during the Covid-19 pandemic.(8–10) Although caring for patients during the pandemic leads to higher burnout scores, staff who worked in ED or critical care before the pandemic had higher burnout levels than other HCWs, implying that burnout in ED staff members was cumulative.(9)
Similar to other studies, CHBAH HCWs were most satisfied with work nature and co-worker relationships, and least satisfied with working conditions and pay.(2,7) Negativity about working conditions by all HCWs was mostly due to the lack of resources and staff. Overcrowding due to a lack of resources, including low staffing levels and not having access to enough ED beds or hospital technology has the greatest negative impact on job satisfaction.(3)
CMJAH staff did not follow the same pattern as other studies.(2,7) CMJAH nurses were least satisfied with work conditions and training. The lack of training and staff development decreases job satisfaction and leads to a higher intention to leave.(11) CMJAH doctors were least satisfied with work conditions and supervision. It is noteworthy that work conditions, which scored low among all groups, was only significantly linked to thinking about leaving, while dissatisfaction with supervision was linked to all three intention to leave questions.
The intention to leave score of staff was higher than HCWs in developed countries.(8) Nurses had a higher intention to leave score than doctors. However, most nurses have been working in their respective units for more than 3 years and almost half of CMJAH nurses more than 7 years. This could indicate that although they intend to leave, their actual turnover is not as high as that of doctors. Promotion opportunities are limited for nurses in SA, and 25% of nurses wanted to leave for this reason.(12) Staff members intending to leave in 2–5 years have not been actively looking for a new job and were not often thinking about it. The intention to leave questions only indicate possible staff turnover over the next year and do not take into account those who will leave later.
A total of 45% of HCWs wanted to leave their current departments. The rest no longer wanted to work in ED or in public health, wanted to emigrate or wanted to change careers. This means that 45% of doctors and nurses may still be available to work in an ED if their reasons for wanting to leave could be addressed.
There were clear differences between the results of the two units. CMJAH staff had higher levels of burnout, lower levels of job satisfaction and higher levels of intention to leave. CMJAH doctors had significantly lower work condition scores. There are several possible explanations. CMJAH is a central referral hospital, receiving mainly priority 1 patients. Furthermore even priority 2 patients are fully diagnosed and managed before discussion with the relative sub-specialities for takeover, instead of admitted for further work-up. CMJAH staff commented on limited options for mental healthcare patients, who may stay in ED for several days before a bed in the ward becomes available. Access block and overcrowding increases stress, decreases job satisfaction, and increases intention to leave.(2,3) Also, HCWs at CMJAH have been working in ED for longer, perhaps because work at a central referral hospital is seen as a superior employment opportunity. Working in any ED for 11–15 years significantly increased the likelihood of wanting to leave as soon as a new job opportunity is found.
Similar to other studies, lower levels of job satisfaction and higher levels of burnout lead to an increased intention to leave.(2,8) Interestingly though, the primary reason for intention to leave was career opportunities and not job satisfaction or burnout. Career related reasons included further study, department or sector change, promotion opportunities or a complete career change. This could be explained by the younger age of this population (most ≤ 40 years), as younger workers are more likely to leave in favour of better opportunities.(11) Anecdotally, the ED is seen as an entry point to gaining valuable skills and experience needed for future career options. However, once HCWs are trained beyond a certain level there are few promotion opportunities in the same unit.
When considering that 42% of HCWs wanted to leave within a year and two-thirds of those wanted to leave as soon as possible, and the fact that 37% of staff have been working in their units for less than a year, it is clear that staff turnover in these units is indeed high.
Recommendations
It is imperative that the Department of Health and hospital management implement strategies to reduce burnout and improve job satisfaction.
Burnout can be reduced by considerate rostering in order to create a better work-life balance and opportunities for debriefing.(13) Supervisors and managers may need training to improve staff burnout recognition, communication and support. Toolkits applied for this purpose have been shown to significantly decrease burnout and to have a visible effect on staff turnover.(14)
Job Satisfaction can be enhanced by improving work conditions and improving remuneration for staff members. Work conditions can be upgraded by ensuring the workplace is modern, clean and functioning, by increasing staffing levels and by planning ways of reducing access block.(2,3) While this is challenging in a resource-limited environments, it may be possible to address the supervision and training concerns of staff.
Emergency departments in tertiary-level hospitals are likely to employ more staff members who are career orientated because of the training opportunities and the academic nature of these units. It will still be possible to retain these HCWs if promotion opportunities, training and supervision are improved.
Limitations
The private sector, allied, auxiliary and administrative staff were not included in the research. This study was planned before the Covid-19 pandemic and while the pandemic was not considered a major factor in the protocol, the authors are mindful that the stress from working in ED during the pandemic may have influenced the negative perceptions of some of the respondents.(9) There are several other aspects that affect burnout and job satisfaction, such as the prevalence of violence, the lack of promotion opportunities, training especially for nurses, and managerial styles were not analysed or assessed in this study and the effect of these factors need further research.
Conclusion
Health care workers in the tertiary level EDs in Johannesburg, South Africa, had a higher level of burnout than their international peers both before and during the Covid-19 pandemic. They had a moderate levels of job satisfaction. However, this research highlighted specific problems affecting job satisfaction which may be more relevant in the South African resource-limited context. The high intention to leave was similar to other middle-income countries, and as expected higher levels of burnout and lower levels of job satisfaction led to an increased intention to leave. However, the primary reasons for intention to leave in this population were career-related.
