Burnout is a response to chronic stress that comprises three dimensions: emotional exhaustion, depersonalization, and personal accomplishment.1 In the context of health care, emotional exhaustion involves the physical and emotional overload resulting from interaction with co-workers and other health care users, while depersonalization refers to the development of cynical attitudes and responses towards fellow workers and the beneficiaries of the services that one provides.1 Reduced personal accomplishment is the tendency to develop a negative self-concept as a consequence of exposure to unrewarding situations.1 Burnout impacts negatively on the performance of an individual, and it leads to diminished job productivity.2 Over the past decade, the prevalence of burnout has been noted to have increased substantially, and in modern working environments, it is becoming a significant problem with potential effects on various sectors of a country's economy (including health care).3
Owing to the nature of their work, nurses are often exposed to more stressful situations compared to other health care workers. They spend more time with patients and are constantly exposed to the emotional strains of caring for the sick and dying. In such situations, environmental demands often exceed individual resources and stress is likely to be perceived.4 Other sources of stress in the nursing profession include role ambiguity, role conflict, work overload, poor interrelationships in the work place, shortage of nurses, lack of opportunities for advancement, lack of support, and poor compensation for overtime.5 Working in such complex settings and facing multiple stressors over time can result in burnout.6 Indeed, it has been shown that compared to the general population and other health care professionals, nurses have higher levels of stress and burnout.7,8
The impact of burnout can be felt in its effects on health care professionals and clinical outcomes, both of which are negatively affected.9 Among physicians and nurses, its relation to high levels of emotional exhaustion leads to an increase in morbidity associated with any related psychiatric disorders these health care workers may have.10 However, nurses are especially vulnerable to work-related mental disorders since their work (patient care, education, management, research, and political participation) consists of actions that depend on intense interpersonal relationships that occur in dynamic and overloaded work contexts.11 Also, burnout in nurses negatively affects the quality of nursing care delivered to patients and family members at a time when humanization in health care is a priority. Further, burnout is not only detrimental to the individual worker, but also to the organization, as it reduces productivity and affects the quality of services provided.2
There have been several attempts at quantifying the burden of burnout. Sirsawy and colleagues12 found the prevalence of burnout among the general working population to be 18%, and this increases to 28% among care-giving professionals such as nurses and doctors. Lorenz and colleagues11 investigated the existence of burnout in a university tertiary hospital using the Maslach Burnout Inventory (MBI). They found the presence of burnout in 7.3% of nurses.11 In another study, Quattrin and colleagues13 found that 35% of nurses had a high level of emotional exhaustion, 17% had a high level of depersonalization, and only 11% had a high level of personal achievement. They also found significantly higher levels of emotional exhaustion among nurses older than 40 years with a working seniority of more than 15 years, those who had chosen to work on an oncology ward, and those who wanted another work assignment. In Singapore, one study identified 39% of nurses to have high emotional exhaustion, 40% to have high depersonalization, 59% to have a low sense of personal accomplishment, and the overall prevalence of burnout was 33.3%, with higher levels of burnout among nurses who worked in rehabilitation wards.9 In Japan, approximately 36% of human services professionals, such as nurses, were burned out compared to 18% of civil servants, and 12% of company employees pointing to the high risk of burnout among nurses.14
Although there is adequate information on the prevalence and risk factors for burnout, the majority of studies have been conducted in well-resourced settings in high-income countries. However, considering that the largest share of the global burden of disease is found in low- and middle-income countries, there is a paucity of data concerning burnout among health care professionals working in such areas, particularly in sub-Saharan Africa where health care systems remain underdeveloped and the impact of burnout on the health care system is un-quantified. This systematic review seeks to close this informational gap by attempting to synthesize the best available evidence on the prevalence of burnout among nurses in sub-Saharan Africa. This evidence will help guide nurses, researchers, and policy-makers in devising ways to counteract its effects and optimize nurse well-being and patient outcomes. A search for similar reviews in MEDLINE, Embase, Cochrane Library, JBI Database of Systematic Reviews and Implementation Reports, and PROSPERO did not yield any results.
What are the prevalence rates for burnout among nurses working in countries within the sub-Saharan Africa region?
This review considered studies that included all levels of nurses directly involved in patient care; midwives were also included in two studies. Studies that assessed burnout in a combined cohort of health care workers (i.e. doctors, nurses, and other allied health practitioners) but had separate data on nurses alone were also considered for inclusion.
This review primarily considered studies that assessed and reported on the prevalence of burnout among nursing staff as determined by the MBI. Studies that reported only the individual components of the MBI (i.e. emotional exhaustion, depersonalization, and personal accomplishment)15 were considered for inclusion as were studies that utilized other validated tools to determine the presence/absence of burnout, and studies that measured/reported burnout using non-validated/unspecified tools. The rationale for this was that such studies still provide a picture of the prevalence of burnout in Africa and omitting them would contribute to a biased outlook.
This review considered both community and hospital-based studies that assessed and reported the prevalence of burnout among nursing staff. Only studies from countries in sub-Saharan Africa were considered.
Types of sources
This review considered observational study designs including prospective and retrospective cohort studies, case-control studies, and cross-sectional studies for inclusion.
Reviews, case series/reports, editorials, studies published as abstracts only or conference proceedings, and letters to the editor were excluded.
This systematic review was conducted in accordance with the JBI methodology for systematic reviews of prevalence16 utilizing an a priori protocol registered in PROSPERO (CRD42018105450).17
The search strategy aimed to find both published and unpublished studies. A three-step search strategy was utilized in this review. An initial limited search of MEDLINE and Embase was undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms was then undertaken across all included databases. Thirdly, the reference lists of all identified articles that were subsequently included in the review were searched for additional studies.
The primary databases that were searched were MEDLINE, African Journals Online, CINAHL, and Embase. The search for unpublished studies and gray literature also included WHO Library and MedNar. In addition, the authors contacted experts in the field for any additional information concerning the review question, although this did not yield any more information.
Initial keywords used were “burnout,” “nurses,” and “Africa.” Only studies published in English were considered for inclusion in this review. Databases were searched from inception to January 2019. The search strategy for all searched databases is shown in Appendix I.
Following the search, all identified citations were collated and uploaded into EndNote X7 (Clarivate Analytics, PA, USA) and duplicates removed. Titles and abstracts were screened by two independent reviewers, and those that did not fit the inclusion criteria for the review were excluded. Studies that seemed to meet the inclusion criteria were retrieved for full-text review and further evaluated by two independent reviewers. Among these studies, those that did not meet the inclusion criteria were excluded and reasons for exclusion noted. Any disagreements that arose between reviewers were resolved through discussion.
Selected studies were assessed for methodological quality by two independent reviewers using the standardized critical appraisal instrument for studies reporting prevalence data available from JBI.16 Any disagreements that arose between reviewers were resolved through discussion. All results were included in the review regardless of the outcome of methodological quality assessment.
Data were extracted from included papers using a standardized data extraction tool for prevalence data available from JBI.16 Two independent reviewers were involved in the process. The data extracted included author names, year of publication and study setting, number and demographic characteristics of study participants, work experience in years, type of tool used to measure burnout, and proportion of participants determined to have burnout in general according to any subscales in a particular tool. Any disagreements that arose between reviewers were resolved through discussion. Where necessary, study authors were contacted to request missing or additional data, but this did not yield additional results.
For each included study, the prevalence of burnout or an aspect of it (as determined by subscales within the measuring tool) was expressed as the proportion/percentage of study participants with burnout as determined by the measuring tool. The 95% confidence intervals (CIs) around these estimates were then determined. Meta-analysis was performed using a random effects model after Freeman-Tukey double arcsine transformation to stabilize variances. All statistical analyses were performed on STATA v.13 (Stata Corp LLC, Texas, USA) using the metaprop command as described by Nyaga et al.18 Heterogeneity was assessed visually and statistically using the standard I2 statistic. Owing to varied socio-economic, geopolitical and other factors, the authors anticipated wide variation in effect estimates. However, because the main objective of this review was to provide an overall picture of the prevalence of burnout in sub-Saharan Africa, the authors did not let high levels of heterogeneity hinder meta-analysis. Although initially planned, subgroup and sensitivity analyses could not be performed for two reasons. First, included studies did not uniformly report variables that could have helped in creating subgroups for further analysis. Secondly, included studies had to be categorized according to the tool used to measure burnout, and this created groups with small numbers of studies thus precluding meaningful subgroup or sensitivity analyses.
A total of 874 potentially relevant studies were identified from the database searches. After correction for duplicates, 702 remained. Of these, 663 were excluded after screening titles and abstracts. The remaining 39 articles were retrieved for full-text review. Of these, 27 articles were excluded and reasons for exclusion noted (Appendix II). The remaining 12 articles met the inclusion criteria and were thus included in this review. Six of the included studies were from South Africa,19-24 two from Nigeria,25,26 and one each from Ethiopia,27 Senegal,28 and Uganda.29 One study enrolled nurses from Kenya, Uganda, and Tanzania.30 Eleven of these studies utilized a cross-sectional survey study design while one study utilized a longitudinal design to survey participants. Using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA)31 format, the study selection process is presented in Figure 1.
All included studies underwent critical appraisal. No study was excluded on the basis of the quality assessment. The reviewers assessed that all studies employed a sample representative of the target population and recruited participants appropriately. The majority of included studies described their subjects and study settings in adequate detail. However, one study did not provide demographic characteristics of included nurses.21 Data analysis was done appropriately in all included studies, and the authors attempted to identify relevant subgroups and employ relevant statistical controls to account for differences. The majority of the included studies employed objective and standard criteria to measure burnout. The tools employed have proven reliability, and some studies even went as far as measuring reliability using Cronbach's alpha. One study was not explicit on the tool used to determine burnout among study participants.23 Ten out of 12 studies answered “Yes” for each critical appraisal question, meaning that the risk of bias across included studies was low. Table 1 gives a summary of the methodological quality of included studies.
Characteristics of included studies
Study participants and setting
A total of 2543 nurses from 12 studies were considered in this review. A cross-sectional study design was used in eight studies.19,21,22,25-27,29,30 Elkonin et al.20 reported using a quantitative exploratory descriptive study design, Rouleau et al.28 used a longitudinal study design, van Wijk et al.23 used a pilot survey, and Wentzel et al.24 utilized a descriptive survey.
Sample sizes ranged from 30 to 542 participants. Mean ages ranged from 28.6 years to 40.3 years. Seven studies reported the mean duration of work experience among recruited participants. In six of these, mean work experience ranged from four years to 18.16 years.19,20,26-29 The remaining study reported that nearly two-thirds of participants had more than five years’ experience working as nurses.24
A total of five studies enrolled a specific cadre of nurses. Two studies exclusively enrolled midwives,28,29 one study focused on intensive care unit nurses,20 another enrolled military nurses,23 while another enrolled oncology nurses.24 The remaining studies stated that nurses from across various hospital units were recruited.19,21,24-27,30 A summary of included studies is presented in Table 2 .
Included studies assessed burnout using three main scales. The MBI was used to assess burnout in seven studies (n = 1,923),19,21,22,25,26,28,30 the Professional Quality of Life (ProQOL) Scale was used in three studies (n = 337),20,24,29 and the Copenhagen Burnout Inventory (CBI) was used in one study (n = 237).27 The final study utilized an unspecified burnout questionnaire (n = 46).23
The MBI is a 22-item tool that measures burnout under three dimensions (emotional exhaustion, depersonalization, and personal achievement). For both emotional exhaustion and depersonalization, higher scores correspond to greater experience of burnout while for personal achievement, lower scores correspond to greater experienced burnout. Only three studies explicitly reported Cronbach's alpha as a measure of internal consistency/reliability of the MBI as applied in the study.19,21,25 The rest either did not report it or assumed it from previous surveys. Only two studies reported the mean values for each of the subscales of the MBI.21,28 While these seven studies reported discrete levels for the presence of each subscale of the MBI (low, moderate, high), the cut-off levels used to determine each level were often not clearly defined. One study21 based its cut-off levels on a study done in the Netherlands,30 and another stated that cut-off values were based on the original report by Maslach and Jackson.32 In five studies, the manual by Maslach and Jackson was the likely basis for the reported cut-off values as it was cited in the methods section of these articles.
ProQOL Scale is a 30-item tool with three subscales (i.e. compassion satisfaction, compassion fatigue, and burnout). Scores for each subscale range from 0 to 50 with higher scores showing higher compassion satisfaction, higher compassion fatigue, and higher burnout. Two studies reported Cronbach's alpha as a measure of internal consistency/reliability.20,29 All studies reported the mean values for the three subscales, but one did not describe the cut-off values used.29 In one study,20 it was unclear how the cut-off values utilized in each subscale were derived, while another study24 stated that cut-off values were employed based on the original study on ProQOL by Stamm et al.33
The CBI is a 19-item tool with three dimensions of burnout (personal burnout, work burnout, and client burnout). It assesses physical and emotional disturbances in terms of their severity and frequency. In the one study27 that utilized this tool, the presence of burnout was determined by calculating the mean CBI score and using this number as a cut-off value for burnout. Participants with scores above the mean were deemed to have burnout. One study utilized an un-named questionnaire and provided no details of how burnout was measured.23 Further details on the measuring tools identified in this review are presented in Table 2 .
Because included studies utilized different tools to measure burnout among nurses, pooling all of them was deemed inappropriate. However, findings from studies utilizing the same tools were pooled separately. Irrespective of the cut-off values used, studies categorized presence of burnout or its subscales as either low or high. The prevalence reported in the following section, therefore, is for high levels of burnout or its subscales.
Generally, the prevalence of burnout among nurses in included studies was high. In the seven studies using the MBI, the prevalence of emotional exhaustion ranged from 33% to 100%. The pooled prevalence was 66% with a 95% CI of 37% to 89% (Figure 2). The prevalence of depersonalization ranged from 29% to 98%. The pooled prevalence was 60% with a 95% CI of 31% to 85% (Figure 3). Low personal achievement had a prevalence ranging from 13% to 99%, with a pooled estimate of 49% with a 95% CI of 19% to 80% (Figure 4). Heterogeneity was determined using the I2 statistic and was found to be very high (>97%) across these analyses. The number of included studies was not sufficient to help in investigating this level of heterogeneity. However, given that the seven studies in this analysis utilized similar definitions for burnout and its components, the observed heterogeneity may be due to a number of reasons. First, studies in this analysis may have used different cut-off levels to define the various sub-categories of burnout. Nonetheless, the impact of this is likely to be small. Second and more importantly, it is possible that the observed heterogeneity may be due to the different contexts in which burnout was measured. Studies included in this analysis were performed in different countries across Africa that have different work environments, which in turn may impact the observed levels of burnout among nurses.
The prevalence of burnout among studies that utilized ProQOL Scale ranged from 61% to 98%. The pooled estimate using this tool was 87% with a 95% CI of 54% to 100% (Figure 5). As with the MBI, heterogeneity as measured by the I2 statistic was very high (>97%) in this analysis. Only three studies assessed burnout using this tool and, therefore, it was not possible to investigate it further or even perform subgroup analysis. As with previous analysis, the high heterogeneity observed here may be due to differences in the context in which burnout was measured.
The prevalence of burnout according to the CBI was 51% with a 95% CI of 44% to 57%, while according to the unspecified questionnaire, it was 33% with a 95% CI of 21% to 47%. Overall, more than a third of the nurses in these studies from sub-Saharan Africa have experienced burnout regardless of the tool used to measure it or the context in which it was measured.
To the best of our knowledge, this is the first attempt at assessing the burden of burnout among nurses in sub-Saharan Africa. Compared to other regions in the world, sub-Saharan Africa bears the largest burden of disease, while at the same time being the least resourced and, therefore, least capable of handling this overwhelming burden. One of the many keys to reversing this trend is having an adequately trained and motivated health care workforce. Burnout is an indicator of an overwhelmed and demotivated workforce, leading to absenteeism, medical errors, and decreased patient safety. These factors are detrimental to the goal of reversing Africa's health care problems as envisioned in sustainable development goal number 3.34
Overall, we report high levels of burnout and its subscales among nurses in sub-Saharan Africa. Up to two-thirds of nurses had emotional exhaustion as determined by the MBI. This is much higher than what is reported in similar reviews. Manslave-Reyes et al.35 reported a prevalence of 28% among primary care nurses from Europe and Latin America, Pradas-Hernández et al.36 reported a prevalence of 31% among pediatric nurses mostly from North America, while Cañadas-De la Fuente et al.37 reported a prevalence of 30% among oncology nurses from Europe, America, and Australasia.
In this review, the prevalence of depersonalization ranged from 29% to 98% with a pooled estimate of 60%. Similar reviews report prevalence ranging from 15% to 21%.35,37 Low personal achievement had an overall prevalence of 49%, which is higher compared to similar reviews that report a prevalence of low personal achievement ranging from 31% to 39%.35,36 The higher burden of burnout noted in this review may be because moderate and high levels of the three components of burnout were combined when determining their prevalence. Primary studies reported results in this way, and it was often not possible to further break down the results. In this review, the prevalence of burnout according to ProQOL was high at 87%. We did not find similar reviews using this tool among nursing populations. Similarly, at 51%, the CBI also indicated a high level of burnout with no opportunity for comparison with similar reviews.
There may be a number of explanations for the high levels of burnout among African nurses. The most obvious one is nursing workforce shortages. Out of the 58 countries in the world with health care staff shortages, 36 are in Africa.38 Nursing as a cadre is particularly affected by this shortage. Worse still, while more nurses are needed throughout the continent, increasing numbers of existing nurses are leaving for better-paying opportunities abroad, thus compounding the problem further. In Kenya, for instance, emigration of highly trained nurses to other countries has contributed to a significant shortage of health workers that almost cripples health care delivery.39 The Ministry of Health in Kenya approximates that there are only 17,000 nurses in the public sector against a need of 35,000.40 In addition to staff shortages, nurses in Africa often work in unsupportive environments. They work longer hours with insufficient supplies and for little pay.41 Such environments are more likely to result in higher levels of burnout, as has been shown in South Africa.42 Further still, elements such as nurse involvement in decision-making43 and autonomy44 (which have been shown to reduce burnout levels) are almost non-existent in most African health care settings.
Besides staff shortages, the complexity of working conditions as seen in sub-specialty practice may also influence burnout levels among nurses. For instance, working in the emergency department may lead to substantial anxiety and burnout,45 while pediatric nurses have been reported to have moderate to high levels of emotional exhaustion and depersonalization.36,46 These findings are similar for oncology nurses.3 There are also unique stressors among nurses in military settings. They often work in outlying hospitals with logistical challenges, reduced emotional support, and shortages – factors that have been postulated to increase burnout.23,47
While the MBI is the most commonly employed tool for determining burnout, the authors identified studies that utilized other tools. These studies did not explicitly mention the reason for not using the MBI; however, it is likely related to a longstanding critique of the MBI. The cut-off values used to dichotomize presence/absence of burnout have been criticized for being arbitrary. They were derived from models that split a normative population into thirds and determined that individuals with “high” burnout were those in the upper third percentile. This approach has been deemed inaccurate. Nonetheless, a closer look at the other tools (i.e. CBI and the ProQOL Scale) still presents this problem, and perhaps more research in this area is warranted.
Inadequate staffing numbers, poor pay, lack of continuing educational opportunities, and poor job satisfaction are some of the issues suggested as underlying factors contributing to burnout among nurses in studies from other parts of the world.48 These factors are similar to those identified in African studies in which the following factors stand out: job insecurity, interpersonal conflicts (with managers and other healthcare professionals), lack of resources, time pressure/workloads, and poor wages.20,21,25,30 Regardless of the underlying problems with the measurement tools, burnout continues to be a significant issue among nurses in sub-Saharan Africa.
The authors acknowledge that this review exhibits some strengths and weaknesses. This review investigated an issue that is relevant and useful for policy makers, clinicians, and researchers alike. Further, an explicit methodology was employed, which reduces the risk of bias in the review findings.
Conversely, only English-language studies were considered for inclusion, which introduces bias in the effect estimates, and resulted in the exclusion of two studies49,50 (one in French and another in Afrikaans). Additionally, there was a high level of heterogeneity observed during meta-analysis. While it was not possible to investigate this further, it is likely that it represents underlying individual, socio-economic, and geopolitical factors in the populations included in the review. Another limitation of this review is that while studies included in meta-analysis reported the proportion of participants with the different facets of burnout, the exact scores used to determine prevalence was not explicitly stated in a number of studies. Nonetheless, the impact of this issue on the overall findings is likely to be small. A final weakness is that of the 12 studies included in this review, half represent one country. This affects the external validity of the findings of this review in terms of their applicability within the African continent.
In conclusion, irrespective of the measuring tool used, nurses in sub-Saharan Africa experience high levels of burnout. They have high rates of emotional exhaustion, high rates of depersonalization, and a low sense of personal achievement.
Recommendations for research
This review contributes useful data on the prevalence of burnout among nurses in sub-Saharan Africa. However, in order to understand this problem further, it is necessary to pursue studies seeking to establish factors that increase nurses’ risk for burnout and strategies that enhance coping. It is also important to note that burnout among nurses in sub-Saharan Africa is measured using tools designed in completely different environments. Future work in this area should look at designing a tool that measures burnout while considering the peculiarities of health care provision in Africa. Finally, it may also be beneficial to have studies that compare levels of burnout among the various cadres of health care professionals working in sub-Saharan Africa.
Recommendations for practice
The findings of this review draw the attention of health care administrators and practitioners to the existence of burnout among nurses in sub-Saharan Africa and the need to develop appropriate measures to prevent or reduce it. Interventions should be aimed at both the individual and the environment in which the individual works (JBI Grade of Recommendation = B).16
Appendix I: Search strategy
(from inception to January 2019; no limits set)
Appendix II: Studies ineligible following full-text review
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