Introduction

The Coronavirus Disease 2019 (COVID-19) is an infectious respiratory disease caused by the SARS-CoV-2 virus with varying degrees of morbidity and mortality depending on the age and fitness of the individual [1]. The virus emerged on 31st December 2019 in Wuhan, Hubei Province, China [2] and was declared a global health emergency on 30th January 2020 and a global pandemic on 11th March 2020 by the World Health Organization [3–5] Sudan reported the first COVID-19 case on 13th March 2020; after the declaration of the first case, the Sudan Federal Ministry of Health enhanced the measures to combat the spread of the virus. On 13th April, after the registration of 10 cases of COVID-19, the authorities announced a total lockdown in the state of Khartoum—the most populated state in Sudan -suspending all gatherings, even prayers in mosques, as the virus spread beyond Khartoum, reaching other states. On 25th May, five isolation centers were established in Khartoum to isolate and deal with COVID-19 cases. Later, the number of isolation centers increased in proportion to the high infection rate of the virus, reaching to 14,401 cases with 1,116 deaths by 11th November 2020, reflecting a high fatality rate of 7.7%. By 7th July 2022, there were 62,745 confirmed cases of COVID-19, with 4,952 deaths in Sudan [6–9].

Although public health measures, such as lockdowns, and social distancing, are crucial to reducing the spread of COVID-19, they were found to increase stress, anxiety, and mental disorders [10]. The World Health Organization has recognized "burnout" as an "occupational phenomenon", as lockdowns have significantly affected our work-life balance and work environment. Much research has ascertained burnout and its contributing factors [11].

COVID-19 has a critical psychological impact on the community [12]. The length of the pandemic period -more than two years-, the low evidence regarding the virus treatment protocols, and the unknown destiny of the pandemic resulted in many studies that showed a significant increase in cases of anxiety, psychological stress, and depressive disorders worldwide.

The medical staff worked under severe psychological pressure: being highly stressed by losing patients and colleagues, preference of having long shifts to protect their families, having no clear prevention strategies, and urgency in instructing interpretation, all incredibly highlight peaking of burnout among healthcare providers [13–16].

Burnout is a critical issue that generates inefficiency in healthcare organizations [13] It lowers the quality of healthcare and negatively impacts patient prognosis [17]. Burnout affects the psychological well-being of the staff leading to medical errors. It makes the health system waste a lot of money and resources- because some workers leave their jobs, compelling the system to recruit new staff and offer a new training program. It impedes the process of psychological support for patients, which is part of the treatment [17, 18] Healthcare providers who are emotionally exhausted -express burnout- can neither support patients psychologically nor make fateful medical decisions.

While the pandemic affects the world, studies show that developed countries are affected less than developing ones in terms of fatality, as it has a higher rate of transmission to elderly coupled with poor access to healthcare facilities [19]. Africa is the most vulnerable region for the impact of higher mortality and morbidity, especially among healthcare providers [16].

Sudan’s revolution, the terrible economic status, collapsing health system, end-stage arrival of cases due to the centralized isolation centers, difficulty of transportation, and stigmatization of COVID-19 cases all affect the mental well-being of healthcare providers. There is no present data regarding burnout among healthcare providers in Sudan. Many published papers confirmed the high prevalence of burnout -in various countries during the pandemic due to diversified factors- leaving no doubt that the crisis is more exacerbated in Sudan [20, 21].

The term ‘Burnout’ entails emotional exhaustion, reduced feelings of achievement, and we personalization [22]. According to studies, the prevalence of burnout among healthcare providers varies from 49.3% to 58% worldwide, and intensivists, emergency department doctors, and nurses are particularly susceptible [23].

Burnout prevalence and its consequences on healthcare workers are not well investigated in Sudan. Still, the stigmatization of mental problems in Sudan and the professional stigma of mental illness proposes that healthcare providers repress their mental suffering, navigating to more emotional stress and susceptibility to burnout [24]. Sudan’s health system has been facing critical challenges, including a lack of personal protective equipment and other necessary medical equipment. As a result, healthcare workers must deal with COVID-19 without the basic equipment to protect the patients and themselves from the infection. Consequently, this puts tremendous pressure on the doctors, largely due to the poor infection control policies and frustration over being unable to deliver the best possible patient care [25].

The extent of burnout, its distribution between workers in different Isolation centers, and its predictors and protective factors are essential for decision-makers. In our study, we will measure the prevalence of burnout among healthcare providers exposed to COVID-19 patients, so we can contribute with data helping decision-makers fight the battle of the COVID-19 pandemic and the hidden pandemic -burnout -.

Material and methods

Results

Participants information

A total of 306 healthcare workers, with the majority being between 26–30 years. More than half of the participants were males (n = 156, 51.0%), and the majority were living in Omdurman (45.1%), followed by Khartoum (42.8%). Also, most of them were singles (83.3%), nurses (58.5%), and only 30 participants (9.8%) were suffering from comorbidities. Regarding the status of COVID-19 in their relatives, 39% stated that their relatives had been infected with COVID-19, while 17.0% were infected and then died. (Table 1).

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 1. Baseline characteristics and demographic data of included participants.

https://doi.org/10.1371/journal.pone.0288638.t001

Most respondents were from Jabra Isolation Center (39%) and Omdurman Teaching Hospital (33%). About 54% of the participants reported working in an ICU and 23% reported having COVID-19. (Table 1).

Burnouts among participants

Responses to the Oldenburg Burnout Inventory (OLBI) are shown in (Table 2). Burnout prevalence was 45.7% among study participants. The number of household members (p = 0.035) and being a doctor (p = 0.003) were associated with burnout among participants. Also, marital status was significantly associated with burnout (p = 0.001) (Table 1). Not surprisingly, fear of infection (p < 0.001) and satisfaction with hospital safety measures (p = 0.002) were associated with burnout.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 2. Responses to questions of the burnout tool.

https://doi.org/10.1371/journal.pone.0288638.t002

The most frequent adaptive behaviors were taking brief mental breaks throughout the day (42.2%) and exercising (37.6%) (Table 3). Interestingly the following factors were not statistically significantly associated with burnout: average income, working years, working hours, extra hours, previous working experience in COVID-19 centers, working center, working site, and fear of patient death despite all measures. (Table 1).

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 3. Adaptive behaviour among the participants.

https://doi.org/10.1371/journal.pone.0288638.t003

The multiple logistic regression showed doctors were more likely to have burnout than nurses (OR: 2.01, CI 95% 1.24–3.27; p = 0.005). Also, married healthcare workers were more likely to suffer burnout than single healthcare workers (OR: 3.89, CI 95% 1.41–12.5; P = 0.013) (Table 4).

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 4. Multiple logistic regression for predictors of burnout among healthcare workers.

https://doi.org/10.1371/journal.pone.0288638.t004

Discussion

Currently, the spread of the novel coronavirus has been deemed a major source of uncertainty, fear and anxiety for a lot of healthcare workers around the world, affecting their physical and psychological health [30]. The current study has assessed burnout among doctors and nurses and provided a better understanding of the problem in sudan. Approximately half of the doctors and nurses in the COVID-19 isolation centers in Khartoum that were included in the present study suffered high levels of work-related stress and burnout in terms of emotional exhaustion and a lack of personal accomplishment and engagement. Physical and emotional well-being of healthcare staff is critical to pandemic containment. However, high burnout rates pose a significant threat to the delivery of safe and effective healthcare, and negatively influence healthcare providers, patients, and the healthcare system.

The prevalence of burnout reported in the current study is In line with previous studies assessing burnout among Sudanese healthcare workers during COVID-19. For instance, 71% of resident physicians in Sudan met the criteria for burnout using the OLBI tool [31]. Another study using the Maslach Burnout Inventory assessment tool revealed that 86.1% of resident physicians in Gezira State’s teaching hospitals had burnout syndrome [32]. Further, these findings align with other countries that have reported high rates of burnout among healthcare workers during COVID-19 pandemic [33–37].

The high rates of burnout in this study can be explained by the psychological demands of the profession and the high level of socioeconomic pressure and work-related stress that lead healthcare workers to burnout [35]. The country’s weak healthcare system, economic meltdown, security situation, political instability and conflicts during this period have placed more pressure on the healthcare system and professionals [36–38]. Moreover, dealing with a high number of patients with poor infrastructure, lack of suitable accommodation and transportation during the lockdown period, concerns about the lack of treatment supplies and personal protective equipment, and the fear of contracting the disease and infecting their families add to the problem [38–40]. Nevertheless, COVID-19 has been ongoing for over two years, and the constant strain may exhaust healthcare workers’ coping mechanisms.

Most of the socio-demographic and other variables assessed in this study were not statistically associated with burnout, reflecting the wide distribution of the problem among the participants despite such differences. We found that a lower number of household members, unmarried individuals, and physician jobs were the only variables associated with burnout among the participants. However, previous studies revealed inconsistent results on burnout risk factors among healthcare workers, and it is unclear whether that burnout follows a specific socio-demographic pattern among healthcare workers [31, 33, 37]. However, some of these associations with socio-demographic factors can be explainable. Among different medical professions, there are differences in the working duties, which put doctors at higher risk of violence and abuse. In our setting, doctors are the front-liners who deal with angry patients and their relatives, particularly when counselling them about their COVID-19 diagnosis and condition or when breaking the news that a patient has passed away [25, 39]. Furthermore, they are responsible for dealing with critically ill patients with a higher risk of complications and mortality [25].

Regarding the habits used to lessen burnout symptoms, seeking professional support to cope with moral distress and grief was significantly associated with lower rates of burnout among the participants. The participants have used other habits to alleviate the burnout symptoms, such as exercising, spiritual habits, and taking brief mental breaks throughout the day. However, none showed a significant association with burnout rates in this study.

The findings of this study acknowledge a high demand for appropriate support interventions and necessitate the search for more effective strategies to be implemented to reduce the risk of burnout among healthcare workers. Using different approaches to reduce burnout, such as training to improve stress-coping skills, can avoid or recover from emotional exhaustion and disengagement. In addition, managing the workplace and environment, improving systems, providing regular psychosocial support, and recruiting additional workers can help address organizational and workplace defects because hostile Working conditions contribute to stress and job dissatisfaction, resulting in depersonalization, emotional exhaustion, and lack of accomplishment [40, 41].

Conclusion

Our study has shown that nearly half of the healthcare workers in isolation centers in Khartoum have suffered from burnout during COVID-19. Several socio-demographic factors have contributed to the increased level of burnout, and multiple coping mechanisms have accounted for a lower level of burnout among healthcare workers. The findings of this study address the high demand for appropriate interventions to be implemented to reduce the risk of burnout among frontline healthcare workers.

Supporting information

Acknowledgments

We want to thank Ahmed Abdalhalim Mohamed Omer, Omer Abdulmajed, Aya Zakareya Noor Hamid, Asmaa Mohamed Abbas, Aldoma Mohammed Adam Ismail, Elhadi elsiddig Elhadi, Mohammed AFEFE Hasan Salim, and Tagwa Badawe for their help in collecting the data and Mazin S. Haroun for his help in the research. Also, we would like to thank healthcare workers for participating in our study.