1. Introduction

Burnout is a psychological syndrome characterized by emotional exhaustion, feelings of helplessness, depersonalization, negative attitudes toward work and life, and a diminished sense of personal accomplishment [1]. It is increasingly recognized as a significant public health concern due to its detrimental effects on both mental and physical health, including chronic fatigue, musculoskeletal pain, gastrointestinal disturbances, and reduced quality of life [2]

Globally, the prevalence of burnout in the general working population of high-income countries ranges between 13% and 27% [3]–[5]. However, healthcare providers (HCPs) are particularly vulnerable due to their work's demanding and emotionally charged nature. Burnout rates among physicians have been reported as high as 70%, and nearly 50% among nurses. In the United States, studies indicate that 54% of physicians, 35% of hospital nurses, and 35.2% of medical students report experiencing burnout. Similar trends have been observed in other high-income countries [2].

Several factors within healthcare systems contribute to the high prevalence of burnout among healthcare professionals. These include excessive workload, time pressures, limited control over work processes, role ambiguity, and strained interprofessional relationships. The emotional demands of clinical care further exacerbate the risk. Burnout prevalence estimates among nurses range from 10% to 70%, and from 30% to 50% among physicians, nurse practitioners, and physician assistants. A 2015 study by the Mayo Clinic and the American Medical Association reported that over half of American physicians exhibited at least one symptom of burnout—an increase of 9% compared to a similar study conducted three years earlier [6].

Burnout has serious implications for the quality of care and patient safety. Clinicians experiencing burnout are more likely to report reduced patient safety, increased medical errors, and a decline in the quality of care delivered. Depersonalization in particular can lead to less empathetic patient interactions and diminished professional engagement [6].

In Sub-Saharan Africa, high levels of burnout among healthcare providers have also been documented. A study conducted in a Malawian referral hospital among maternal health staff found that 72% experienced emotional exhaustion, 43% reported depersonalization, and 74% indicated low personal accomplishment [7]. In Rwanda, Emeline (2017) reported that 61.7% of nurses working in the Emergency Department and Intensive Care Unit at Kigali University Teaching Hospital exhibited at least one indicator of burnout, with emotional exhaustion at 48.3%, depersonalization at 25.0%, and low personal accomplishment at 50.0% [8]. Another study conducted among anesthesia providers in 11 district and tertiary hospitals across Rwanda found a burnout prevalence of 26.3% [9].

In Rwanda, despite ongoing efforts by the Government of Rwanda to promote safe and healthy working environments through labor policies and workplace programs[10], healthcare providers continue to face high levels of occupational stress. Contributing factors include workforce shortages, extended working hours, and the inherently demanding nature of healthcare services.

In Rwanda, despite ongoing policy efforts by the Ministry of Public Service and Labour to improve workplace conditions [10], , healthcare providers remain vulnerable to occupational burnout. This is often attributed to systemic challenges such as workforce shortages, long working hours, and the emotionally demanding nature of healthcare services.

Therefore, this study aims to assess the determinants of burnout and explore the effective coping practices employed by healthcare providers working at Butare University Teaching Hospital (CHUB) and the District Hospitals (DHs) within its catchment area. The findings are expected to inform institutional and national strategies to mitigate burnout, enhance the resilience of Rwanda’s health workforce, and improve the quality of patient care.

2. Research methodology

5.1 Study design

This study was a cross-sectional study using a survey approach to collect quantitative data from the study participants.

5.2 Study Area

The research aimed to collect data from Butare Univeristy Teaching Hospital (BUTH) and 9 hospitals in its catchment areas including Kabutare DH (Huye), Kibilizi DH and Gakoma DH(Gisagara), Kabgayi DH (Muhanga), Bushenge and Kibogora DHs (Nyamasheke), Nyanza DH (Nyanza), Munini DH (Nyaruguru), and Gitwe and Ruhango DHs (Ruhango).

5.3 Study population and sample size

The study collected data from 374 healthcare providers including Nurses, General practitioners, Specialized   Physicians, and Laboratory technologists working in selected services, including Critical care (CBUB), Emergency, labor and delivery (Maternity), Surgery, and internal medicine departments. This number is calculated using the following Yamane formula for a finite population.

n=N1+N(e)2   where:

N: population size (2160),

e: margin of error held at 5%

n=21601+2160(0.05)2= 337.5

Therefore, the current study will collect data from 337 HCPs. However, to adjust missing or incomplete responses, 10% of the sample size was added; equivalent to approximately 34 people. Thus, 374 Healthcare providers were recruited for this study.

5.4 Inclusion and exclusion criteria

Below are the inclusion and exclusion criteria for study participation.

5.5 Inclusion and exclusion criteria

Healthcare providers were included in the study if they were voluntarily willing to participate in the study, had been working in selected hospitals for at least 6 months, had at least two years of working experience, and were aged 18 years by the time of data collection.

5.6 Exclusion Criteria

All participants fulfilling inclusion criteria were excluded from the study if they had an illness that prevented them from correctly and accurately answering survey questions.

5.7 Data collection tools

This study used a questionnaire (Appendix B) to collect the required data. The questionnaire collects data on demography, burnout core symptoms to measure exhaustion, mental distance, cognitive impairment, and emotional impairment, and burnout secondary symptoms including psychological and psychosomatic complaints. It also captures information on stress-coping practices among the study participants. Questions were adapted from Maslash Burnout Inventory(MBI)[11], [12]

5.8 Data collection process

After receiving ethical approval from the CHUB Research committee, we planned to reach the participant for a face-to-face interview guided by a questionnaire (Appendix B). Data were collected using an open data kit (ODK) form. Data collection was conducted from August 28 to October 8, 2023.

5.9 Data analysis

After collecting data, we will analyze data using STATA 15 version for quantitative analysis while quantitative data were analyzed using thematic analysis.  Data were analyzed at univariable, bivariable, and multivariable analysis levels. A Chi-square test was computed to test the significance of the association, which was assumed at a p-value less than 0.05 and a 95% confidence interval. Findings are presented in tables and figures.

5.10 Ethical Consideration and Confidentiality

Following the Helsinki declaration, this study adhered to ethical research considerations including ethical review and informed consent. An ethical clearance letter (Approval Notice: No: REC/UTHB/058 /2023) was obtained from Butare Univerity Hospital Institutional Review Board.  and informed consent was obtained from the study participants before data collection. Moreover, collected data were kept confidential and used for research purposes only.

3. Results

This study was conducted to determine the prevalence of burnout syndrome and factors associated with having burnout core symptoms among healthcare providers. It was also conducted to determine coping strategies associated with less likelihood of having burnout core symptoms. Below are findings on the study objectives along with a description of the study participants.

3.1 Sociodemographic characteristics of the study participants

The larger proportion of the study participants had 11 to 28 years of working experience (43.5%), were catholic church members (58.6%), and were working in internal medicine or the emergency department (18.7%).

This study surveyed 374 healthcare workers across various hospitals, with the majority being nurses (78%) and highly educated (98.9% university level or higher). The workforce was predominantly female (62%), and the largest age group was 31-40 years (51.3%). Most participants had 1 to 3 children (59%), and 78.3% were satisfied with their marital status. Economic stability appeared strong, with 96.5% in economic category III, and only 10.7% had secondary jobs (mostly schooling or part-time work). Regarding work experience, 43.5% had over 11 years in the profession, and 43.6% had been at their current hospital for 1-5 years. The most commonly assigned wards were surgery (20.6%), emergency care (18.7%), and internal medicine (18.7%). Around 97.1% had not experienced intimate partner violence in the past year, and the workforce was largely religious, with 58.6% identifying as Catholic. Table 1 shows the socio-demographic characteristics. Table 1 provides further information about the socio-demographic characteristics of the study participants.

Table 1: Socio-demographic of the study participants

*Other occupation

3.2 Prevalence and categories of burnout among healthcare providers

Using a scale of 1 to 5, with 1 standing for lowest frequency and 5 for highest (1. Never, 2. Rarely, 3. Sometimes, 4. Often, and 5. Always), participants rated how they experience burnout core-symptoms listed in appendix B (e.g.: like When I exert myself at work, I quickly get tired for exhaustion). Participants who responded to experience the symptoms often or always were considered to have the core symptoms and thus, burnout.

Based on the participants’ responses to burnout assessment questions (Appendix B) assessing core symptoms of burnout core symptoms including those of exhaustion, cognitive impairment, emotional impairment, and mental distress. This study shows that about 22.4% of the interviewed healthcare providers reported sufficient or extreme amounts of burnout core symptoms. About 16.5% of the health care workers were having symptoms of exhaustion, while 9.3% had mental distress symptoms. Rates of cognitive impairment and emotional impairment symptoms were relatively lower, with 4.5% and 5.1%, respectively. Figure 1 and Table 2 show further information. Appendix A provides detailed information on participants' responses about felt burnout symptoms used to classify presence or absence of burnout for this research

Figure 1:  Prevalence of core burnout symptoms among healthcare workers

Table 2: Burnout core symptoms identified among healthcare providers

3.3 Factors associated with having one or more burnout core symptoms

To determine factors associated with burnout symptoms, participants’ characteristics were cross-tabulated with having burnout symptoms. Several variables showed statistical significance at p value less than 0.05. Statistically significantly higher proportions of healthcare workers with burnout core symptoms were among Midwives (66.67%), participants with secondary education (75%), 4 children and above (45.0%), happy in their current marital status (25.2%), working in their hospitals for 11 to 28 years (29.5%) and those working in Gyneco-obstetric unit (44.3%).

All variables associated with having one or more burnout core symptom(s) were put in one logistic regression model, and only one variable was statistically associated with having burnout core symptoms. Healthcare providers working in Gyneco-obstetric units were 5.7 times more likely to have burnout than those working in ICU units (aOR: 5.7 with 95% CI:1.1-29.9). Table 3 provides further information.

Table 3: Socio-demographic characteristics associated with burnout among healthcare workers

3.4 Stress-coping mechanisms and burnout among healthcare providers

To determine burnout coping strategies associated with less likelihood of burnout among healthcare symptoms, we cross-tabulated the frequency at which providers exercise various coping mechanisms and experience of burnout. Several coping mechanisms were found associated with less likelihood of burnout among the health care providers and they include taking a full day off frequently or weekly (16.4%), having frequent or daily time out to think, reflect, meditate, or pray (17.7%), doing aerobic exercise frequently or 3 to 5 times a week (8.9%), and ability to always or mostly say no to inappropriate or excessive demands (13.7.

All coping mechanisms were put in one logistic regression model to find the strength and direction of association with burnout. Only one variable showed significant association with burnout among the healthcare provides (HCPs). Inability to consistently or mostly say no to inappropriate or excessive demands was associated with a 2.1 times higher likelihood (aOR: 2.1, 95% CI: 1.1–4.1) of experiencing burnout core symptoms. Similarly, healthcare workers who occasionally, seldom, or never sleep well at night for at least 8 to 9 hours were 2.7 times more likely (aOR: 2.7, 95% CI: 1.1–6.5) to experience these symptoms compared to those who always or mostly sleep well.

Considering adoption range preventative measures to cope with burnout among healthcare providers, participants' score on several adopted coping mechanisms were grouped into a wide range (60-100), adequate (40-59), moderately inadequate (30 to 39), and moderate inadequate (0 to 29) coping mechanisms. The current study shows that the adoption of more burnout coping mechanisms is associated with a less likelihood of burnout among healthcare providers. HCPs with moderately inadequate coping mechanisms were 3.2 (aOR: 3.2 with 95% CI: 1.5-7.0) times more likely to present burnout than those with a wide range of coping mechanisms. Thus, this study shows that the risks of presenting one or more burnout core symptoms significantly decline with the number of stress-coping mechanisms. Table 4 provides further information.

Table 4: Association between stress-coping mechanisms and burnout among healthcare providers