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Indicator 12: Health workforce wellbeing

This indicator measures the proportion of facilities with high levels of health workforce burnout.

Numerator:No. facilities with EmONC-related health workforce reporting high burnout

Denominator:Total no. facilities assessed

× 100

Purpose

Health workforce wellbeing has been the subject of study in recent years, especially in high income settings12 and highlighted since the advent of the COVID-19 global pandemic345. Reduced health worker wellbeing is associated with poor patient outcomes, such as medication errors, malpractice, and poor communication with patients.6 Wellbeing in general is multidimensional and complex;78 so, too, in the context of EmONC. Indicators to track and measure EmONC workforce wellbeing in low resource settings are needed to promote system awareness, improvement, and accountability.

The EmONC Framework uses burnout as the core red flag indicator of serious problems with health worker wellbeing. Burnout is a complex, multidimensional, physiological, and psychological syndrome arising in the context of chronic, unabated workplace stressors and energy resource depletion,910 and commonly characterized by emotional exhaustion, physical fatigue, and cognitive exhaustion.1112 The prevalence of provider burnout is substantial in low- and middle- income countries, regions that often experience staffing and resource shortages.131415 As many as 9 out of 10 health workers in some regions in sub-Saharan Africa experience some degree of burnout.16 For example, a mixed-methods study with maternity providers in a rural county in western Kenya found that 65% of providers experienced low burnout and 19.6% of providers experienced high burnout.17 Additionally, a cross-sectional study of maternity health providers in the Upper East region of Ghana found that 7 out of 10 providers had some level of burnout, 5.4% of which had high levels of burnout that were cause for clinical concern.18

There are a number of validated instruments that have been developed to measure burnout. One such instrument is the Shirom-Melamed Burnout Measure (SMBM) which assesses health workers’ feelings at work in the past month. Conceptually drawn from Conservation of Resources (COR) theory,19 the 14-item SMBM operationally defines and measures three components of burnout: physical fatigue (feelings of tiredness and low energy), emotional exhaustion (lack of the energy to display empathy to others), and cognitive weariness (feelings of reduced mental agility).20

The SMBM was validated in Israel and Switzerland for use among health workers and other professionals,21222324 with evidence of its reliability over time25 and links with adverse physical symptoms.2627 It has since been utilized in studies measuring burnout among healthcare workers in the context of COVID-19 in high, middle, and low income countries,282930 and specifically among maternity providers in Ghana and Kenya.3132

Levels of burnout are categorized based on a respondent’s average SMBM score, with scores greater than or equal to 3.75 representing high burnout, scores between 2.1 and 3.74 indicating moderate burnout, and scores less than or equal to 2.0 indicating no burnout.333435 The SMBM score can be used to determine the overall level of burnout and for each of the three subscales.

For the purposes of measuring burnout within the context of EmONC, we present one example of an indicator built around the SMBM.

Data collection and calculation

The numerator for this indicator is the number of facilities with EmONC-related health workforce reporting high burnout. Burnout is measured with the Shirom-Melamed Burnout Measure (SMBM); when health providers have an average score greater than or equal to 3.75 on the SMBM, they are considered to have ‘high burnout’. The process, including worksheets, for determining the number of facilities with high levels of health workforce burnout can be found in Health workforce burnout scale, process and instructions for use. (If a country chooses to use a different scale or measure of burnout than the SMBM, the linked instructions may still be useful for converting that measure into an indicator.)

The denominator for this indicator is the number of facilities being assessed.

This indicator is expressed as a percentage.

The SMBM should be administered over a period of one to three months every year to health workers providing EmONC services (in maternity units, surgical units, SNCUs, ICU/NICUs). Data should be collected by sub-national or national managers through individual, anonymous surveys. The use of secure online survey platforms is recommended (e.g., KoboToolbox, Survey Monkey). A sample data collection form can be found in Health workforce burnout scale, process and instructions for use.

The indicator should be calculated by managers at the national or sub-national level on an annual basis.

Analysis and interpretation

If the proportion of facilities with high levels of health workforce burnout is greater than 0, further investigation may be required. Disaggregation by EmONC classification, level of facility, sub-national area and/or other facility characteristics such as commodity readiness or whether they have adequate staffing levels may uncover systemic problems and related solutions.

If provider characteristics (e.g., cadre, length of service, gender) are added to burnout surveys (for example, see Health workforce burnout scale, process and instructions for use), further disaggregation can be conducted to identify whether experiences of burnout differ amongst various groups of health providers. For example, does one cadre experience higher rates of burnout than other cadres?

Supplemental studies

The proportion of facilities with a health workforce experiencing high burnout serves the purpose of raising a “red flag” and, for the purposes of the EmONC Framework, it functions as a proxy for overall health worker wellbeing. However, to more comprehensively assess the wellbeing of health workers, additional aspects should be explored. In a systematic study,36 two constructs that were found to be important to the delivery of good-quality EmONC were moral distress and psychological safety:

Moral distress is defined as the result of perceived pressure to act unethically with little power to change the situation and may occur when professional standards of care are not met due to institutional constraints.3738

Psychological safety is a complex, multi-dimensional phenomenon defined as the perception that it is safe to take interpersonal risks within a team, commonly characterized by the perception that it is safe to speak up, safe to take a risk including openly questioning other members of the team or one's superiors, and safe to say something when errors or risks are identified,394041424344 thus allowing for errors to be identified by any member of the team and learned from.45 For example, team members may refrain from bringing up problems or asking questions about something they do not know because they are concerned there will be negative consequences (e.g., being seen as incompetent, being blamed, retaliation). However, if team members respect and feel respected by the other members of the team and feel confident that their errors or questions will not be held against them and instead used as a learning opportunity, they are more likely to see speaking up as being beneficial for team performance.46

Although moral distress and psychological safety have been understudied in low- and middle-income countries, these constructs may provide useful supplementary information to help planners better understand the nature of the threats to wellbeing experienced by their health workforce. To measure moral distress, we recommend the use of the Moral Distress Thermometer.47 Psychological safety can be measured using the SOPS Hospital Survey 2.0,48 Psychological safety in healthcare teams,49 or the Safety attitudes and safety climate questionnaire.50

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