3.1 QUAN strand: Cross-Sectional Survey
In the QUAN strand, a total of 1037 physicians participated in the cross-sectional survey. 64 responses were excluded because participants did not provide informed consent or did not meet the inclusion criterion. Thus, the final number of responses included in the quantitative analysis was 973. Regarding the sociodemographic profile of respondents, the mean age was 34.6 ± 9.9 with 68.4% being within the age group (24–34) years. Most physicians were males (n = 679, 69.8%), married (n = 585, 60.1%), living with household members of one to three persons (n = 461, 47.4%), own their flats or houses (n = 663, 6.81%), living in central governorates (n = 764, 78.5%), non-smokers (n = 569, 58.5%), and of income category 700–1400 Jordanian Dinars (n = 412 ,42.3%). The respondents’ work profile showed that most physicians were classified as resident doctors (n = 444, 45.6%), from medical specialties/departments (n = 559, 57.5%), working at JMOH hospitals (n = 312, 32.1%), involved in a full-time job (n = 833, 85.6%), working more than 48 hours per week (n = 380 ,39.1%), doing 1–3 night shifts per week (n = 547, 56.2%), had sufficient access to PPE at workplace (n = 532, 54.7%), did not receive any financial incentives while working during pandemic crisis (n = 900, 92.5%). Besides, 154 physicians (15.8%) were positively tested for SARS-CoV-2. Tables 1 and 2 show more descriptive details about the sociodemographic and work profile of respondents in the cross-sectional survey, including more details about variables’ categorization.
Table 1
Socio-Demographic Profile of Physicians who Participated in Cross-Sectional Survey, Total Number of Participants = 973
Variables | N (%) |
Age (Mean ± SD, Range) | 34.6, 9.9, 24–77 |
(24–34) | 666 (68.4) |
(35–45) | 193 (19.8) |
(46–56) | 53 (5.4) |
(57–77) | 61 (6.3) |
Gender | |
Male | 679 (69.8) |
Female | 294 (30.2) |
Marital Status | |
Single (never married, divorced, widowed) | 388 (39.9) |
Married | 585 (60.1) |
Household Members | |
1–3 Persons | 461 (47.4) |
4–6 Persons | 379 (39.0) |
> 6 Persons | 133 (13.7) |
Residence Place | |
Rented | 310 (31.9) |
Owned | 663 (6.81) |
Geographical Region of Residence | |
Northern Governorates | 167 (17.2) |
Central Governorates | 764 (78.5) |
Southern Governorates | 42 (4.3) |
Smoking Status | |
Non-Smoker | 569 (58.5) |
Smoker | 404 (41.5) |
Table 2
Work Profile of Physicians who Participated in Cross-Sectional Survey, Total Number of Participants = 973
Variables | N (%) |
Speciality Discipline | |
Medical | 559 (57.5) |
Surgical | 414 (42.5) |
Professional Classification | |
General Practitioner | 148 (15.2) |
Resident | 444 (45.6) |
Specialist | 241 (24.8) |
Consultant | 140 (14.4) |
Workplace | |
JMOH | 312 (32.1) |
JRMS | 252 (25.9) |
PHs | 279 (28.7) |
NGOs | 38 (3.9) |
UHs | 92 (9.5) |
Job Status | |
Full-Time | 833 (85.6) |
Part-Time | 140 (14.4) |
Average Monthly Salary | |
< 700 JDs | 372 (38.2) |
700–1400 JDs | 412 (42.3) |
> 1400 JDs | 189 (19.4) |
Duty Hours/Week | |
< 40 | 221 (22.7) |
40–48 | 372 (38.2) |
> 48 | 380 (39.1) |
Night shifts/Week | |
None | 300 (30.8) |
1–3 | 547 (56.2) |
> 3 | 126 (12.9) |
Sufficient PPE at Workplace | |
Yes | 532 (54.7) |
No | 441 (45.3) |
COVID-19 Related Financial Incentives | |
Yes | 73 (7.5) |
No | 900 (92.5) |
Tested Positive for SARS-COV-2 | |
Yes | 154 (15.8) |
No | 819 (84.2) |
┼JMOH: Jordanian Ministry of Health, JRMS: Jordanian Royal Medical Services, NGOs: Non-Governmental Organizations, PHs: Private Hospitals, UHs: University Hospitals, PPE: Personal Protective Equipment, JDs: Jordanian Dinars (official currency of Jordan, 1 JD = 1.4 U.S. Dollars) |
Based on the burnout score’s cut-off point (≥ 4), and out of the total sample (n = 973, 100%), 376 male physicians (38.7%) and 185 female physicians (19.0%) were found to suffer from burnout; thus, the overall prevalence of burnout among physicians in our study was 57.7%
The logistic regression model revealed several explanatory variables that act as potential predictors of occupational burnout among physicians in our study, including being a female physician was associated with statistically significant higher odds of suffering from burnout (aOR = 1.445, P = 0.030, 95% CI: 1.035, 2.017) compared to males as a reference category. In addition, working at JMOH and JRMS hospitals was found to be associated with higher possibilities of suffering from burnout with (aOR = 2.377, P = 0.002, 95% CI: 1.359, 4.155) and (aOR = 2.258, P = 0.006, 95% CI: 1.269, 4.019), respectively. Physicians who worked more than 48 hours/week (aOR = 1.585, P = 0.043, 95% CI: 1.016, 2.474), had one to three night shifts/week (aOR = 2.078, P < 0.001, 95% CI: 1.438, 3.003), had more than three night shifts/week (aOR = 2.101, P = 0.007, 95% CI: 1.230, 3.590), with no sufficient access to PPE at workplace (aOR = 2.754, P < 0.001, 95% CI: 2.038, 3.723), and with confirmed COVID-19 status (aOR = 1.626, P = 0.026, 95% CI: 1.061, 2.491) were found to act as statistically significant predictors for suffering from occupational burnout compared to their corresponding reference categories. See Table 3 for a more detailed representation of logistic regression results.
Table 3
Results of Multivariable Logistic Regression for the association between Burnout and Sociodemographic/Work factors (final model).
Predictors | Adjusted Odds Ratio | 95% Confidence Interval | P-value |
Lower | Upper |
Age | 0.982 | 0.963 | 1.002 | 0.81 |
Gender | | | | |
Male (Reference) | | | | |
Female | 1.445 | 1.035 | 2.017 | 0.030 |
Workplace | | | | |
UHs (Reference) | | | | |
JMOH | 2.377 | 1.359 | 4.155 | 0.002 |
JRMS | 2.258 | 1.269 | 4.019 | 0.006 |
PHs | 1.276 | 0.731 | 2.230 | 0.391 |
NGOs | 1.805 | 0.775 | 4.205 | 0.171 |
Monthly Income | | | | |
> 1400 JDs (Reference) | | | | |
< 700 JDs | 1.867 | 1.116 | 3.123 | 0.017 |
700–1400 JDs | 1.347 | 0.852 | 2.129 | 0.203 |
Duty Hours/Week | | | | |
< 40 (Reference) | | | | |
40–48 | 0.887 | 0.601 | 1.311 | 0.548 |
> 48 | 1.585 | 1.016 | 2.474 | 0.043 |
Night Shifts/Week | | | | |
None (Reference) | | | | |
1–3 | 2.078 | 1.438 | 3.003 | < 0.001 |
> 3 | 2.101 | 1.230 | 3.590 | 0.007 |
Sufficient PPE | | | | |
Yes (Reference) | | | | |
No | 2.754 | 2.038 | 3.723 | < 0.001 |
SARS-CoV-2 Infection | | | | |
No (Reference) | | | | |
Yes | 1.626 | 1.061 | 2.491 | 0.026 |
┼ Statistically significant P values at P < 0.05 are in Bold. Model’s Nagelkere R2 = 0.274, Hosmer and Lameshow test : X2 (8) = 9.001, P-value = 0.342, JMOH: Jordanian Ministry of Health, JRMS: Jordanian Royal Medical Services, NGOs: Non-Governmental Organizations, PHs: Private Hospitals, UHs: University Hospitals, PPE : Personal Protective Equipment, JDs: Jordanian Dinars (official currency of Jordan, 1 JD = 1.4 U.S. Dollars) |
As described in the methodology, job satisfaction using the 5-item SIJS scale has an overall value between 5 and 25 with no cut-off scores; thus, the higher the score, the more job satisfaction. The mean score (± SD) of job satisfaction among male physicians and female physicians was 15.3 (± 3.98) and 15.5 (± 3.80), respectively. However, this difference in job satisfaction scores between different gender was statistically not significant (P = 0.562). The multiple linear regression model revealed that with an increase in age, there is a statistically significant increase in job satisfaction (β = 0.066, P = 0.017, 95% CI: 0.005, 0.047). Expectedly, the level of burnout was a significant predictor of job satisfaction, that is, having higher scores of burnout leads to lower levels of job satisfaction (β= -0.600, P = < 0.001, 95% CI: -2.225, -1.888). In addition, being a general practitioner or a specialist predicted lower levels of job satisfaction (β= -0.092, P = < 0.001, 95% CI: -1.597, -0.472) and (β= -0.070, P = 0.006, 95% CI: -1.087, -0.180), respectively, compared to reference category. Moreover, working at JMOH hospitals (β= -0.147, P = < 0.001, 95% CI: -1.678, -0.793), working at JRMS hospitals (β= -0.095, P = < 0.001, 95% CI: -1.346, -0.359) having a monthly income less than 700 Jordanian Dinars (β= -0.080, P = 0.008, 95% CI: -1.115, -0.170) predicted lower levels of job satisfaction compared to their reference categories. See Table 4 for detailed results.
Table 4
Results of Multivariable Linear Regression for the association between Job Satisfaction Score and Sociodemographic/Work factors (final model).
Predictors | βcoefficient | P-value | 95% Confidence Interval |
Lower | Upper |
Age | 0.066 | 0.017 | 0.005 | 0.047 |
Burnout | -0.600 | < 0.001 | -2.225 | -1.888 |
Smoking Status | | | | |
Non-Smoker (Reference) | | | | |
Smoker | -0.054 | 0.021 | -0.795 | -0.064 |
Workplace | | | | |
UHs (Reference) | | | | |
JMOH | -0.147 | < 0.001 | -1.678 | -0.793 |
JRMS | -0.095 | < 0.001 | -1.346 | -0.359 |
Professional Classification | | | | |
Consultant (Reference) | | | | |
General Practitioner | -0.092 | < 0.001 | -1.597 | -0.472 |
Specialist | -0.070 | 0.006 | -1.087 | -0.180 |
Monthly Income | | | | |
> 1400 JDs (Reference) | | | | |
< 700 JDs | -0.080 | 0.008 | -1.115 | -0.170 |
┼ Statistically significant P values at P < 0.05 are in Bold, model’s adjusted R2 = 0.467, other variable categories and subcategories were not chosen by the stepwise forward regression algorithm. JMOH: Jordanian Ministry of Health, JRMS: Jordanian Royal Medical Services, UHs: University Hospitals, JDs: Jordanian Dinars (official currency of Jordan, 1 JD = 1.4 U.S. Dollars) |
3.2 QUAL strand: Individual Interviews
A total of 11 physicians were interviewed. Table 5 shows a concise representation of the interviewees’ characteristics. In this strand, four main themes have emerged from the qualitative thematic analysis, namely (i) Work-induced psychological distress during the COVID-19 pandemic, (ii) Decision-driven satisfactory and dissatisfactory experiences, (iii) Impact of the pandemic on doctor-patient communication and professional skills, and lastly, (iv) The economic impacts of the pandemic crisis and lockdown.
Table 5
Characteristics of Physicians who participated in Semi-Structured Individual Interviews.
No. of Interviewees | n = 11 |
Age (mean, range) | 36.2, 28–56 |
Marital Status | Single (n = 3), Married (n = 8) |
Workplace | Jordanian Royal Medical Services (n = 3), Jordanian Ministry of Health (n = 3), Private Hospitals/Clinics (n = 5) |
Classification | General Practitioner (n = 2), Resident (n = 5), Specialist (n = 2), Consultant (n = 2) |
Speciality Discipline | Orthopedics (n = 1), Pediatrics (n = 1), General Practice (n = 2), Ophthalmology (n = 1), Internal Medicine (n = 2), Neurosurgery (n = 1), Intensive Care (n = 1), Otorhinolaryngology (n = 1), Radiology (n = 1) |
Theme 1
Work-induced psychological distress during the COVID-19 pandemic
During the current pandemic, physicians were exposed to higher levels of workload putting a significant burden on their physical and psychological well-being. Most of the physicians who participated in the interviews reported fear and anxiety related to their medical practice amid the pandemic crisis. The fear and anxiety were mainly a result of thier worries about catching the virus and transmitting it to their family members. This could be expected to act as a contributing factor to their emotional and mental exhaustion; thus, making them more vulnerable to suffer from burnout.
A physician said:
…There is significant distress during my work amid the COVID-19 pandemic due to being fearful of transmitting the infection to my family after returning to home …
(Participant #1, Male, Private Sector)
Also, another physician added the following:
…After a day of clinical practice, the most anxious thing is being afraid of being infected as well as transmitting the virus to my family and elderly household members…
(Participant #2, Male, Private Sector)
In addition, the rising COVID-19 morbidity and mortality in Jordan was also another factor that afflicted the psychological status of physicians.
…I feel a significant degree of psychological distress due to the increasing number of COVID-19 cases and deaths in our community and during my daily practice…
(Participant #6, Male, JMOH)
Alongside distress, an intensivist physician has said:
“…As an intensivist, I finish my duty with deep sadness considering the levels of suffering I observe among COVID-19 patients at the critical care unit accompanied by the rising number of deaths…” (Participant #5, Male, Private Sector)
Theme 2
Decision-driven satisfactory and dissatisfactory experiences
In the interviews, physicians have reported numerous satisfactory and dissatisfactory job experiences during their clinical practice amidst the COVID-19 pandemic. The experiences were attributed to various pandemic-related decisions at institutional, sectoral as well as national levels, such as decisions on PPE supply, health workforce, and the COVID-19 control measures. These experiences whether satisfactory or dissatisfactory could have a profound impact on the level of job satisfaction as well as the emotional and physical well-being of physicians. A physician has said:
…I think that the protocols implemented at my workplace during the COVID-19 pandemic were satisfactory to me from a practice perspective, but they could have been better than that...
(Participant #1, Male, Private Sector)
And another physician added:
…I noticed a lack of experience as well as many conflicting decisions among the managerial panel at my workplace, especially decisions regarding health workforce capacity and personal protective equipment supply. More health care professionals, especially nurses and doctors are needed at critical care units during the COVID-19 crisis…
(Participant #5, Male, Private Sector)
Other physicians have expressed the impact of imposed measures and decisions on the level of job satisfaction:
…In my opinion, reluctant and irrational decisions imposed by the pandemic taskforce, false information in the society as well as the lack of transparency in governmental speech, were all dissatisfactory to me in terms of my personal and professional life aspects...
(Participant #10, Male, Private Sector)
…I felt a swing between satisfaction and dissatisfaction during my duty, depending on the availability of personal protective equipment at the workplace and the effectiveness of patients triaging system during my shift…
(Participant #11, Female, JRMS)
Moreover, collaborative efforts at the workplace were described as a motivational factor for a better and more efficient engagement in work:
…As a healthcare professional, I feel proud of my sacrifices during the COVID-19 pandemic … the spirit of collaborative teamwork has motivated me during my work amid this crisis…
(Participant #8, Female, JRMS)
Acknowledgments and financial incentives are considered important factors for motivating employees to be more productive. A physician has mentioned that reliable acknowledgment is also needed to encourage healthcare workers to provide more, and to compensate them as well:
“…There should be a reliable acknowledgment to healthcare workers during the pandemic crisis, emotionally and financially, considering the sacrifices we provide every day...”
(Participant #6, Male, JMOH)
As found in the QUAN strand, various explanatory predictors have been identified as risk factors for occupational burnout among the participating physicians. Some of these predictors such as workplace environment, workload, and the availability of PPE were also reported by physicians who participated in the interviews. Besides, law enforcement of mask-wearing and pandemic-related managerial decisions were expressed to exhibit a significant impact on physicians. For example, some physicians have expressed positive opinions regarding some pandemic-related decisions on COVID-19 precautionary measures as well as the extent of non-emergent healthcare services at their workplaces:
…In my opinion, obligatory mask-wearing was amongst the most vital decisions which were legally enforced by the government recently to limit the viral spread in my workplace environment, and this has positively impacted my work conditions and medical practice…
(Participant #1, Male, Private Sector)
…I believe that many good decisions were taken by decision-makers, such as limiting non-emergent healthcare services to reduce the possibility of COVID-19 community spread and reducing the risk of COVID-19 spread at workplace ..
(Participant #8, Female, JRMS)
On contrary, other physicians believed that many pandemic-related decisions at workplaces were not taken properly, in terms of lack of sufficient access to PPE, higher workload (day and night shifts), and limited health workforce:
…I did not notice any escalation of precautionary measures at my workplace except for more monitoring of mask-wearing among healthcare workers and visitors…
(Participant #3, Male, JMOH)
Moreover, Physicians have pointed to the emotional and physical fatigue caused by higher workload which has negatively impacted their satisfaction:
…Overall, I am not satisfied with working conditions at my workplace during the COVID-19 pandemic. Lack of a sufficient number of healthcare workers, as well as the lack of a unified protocol to be followed in dealing with suspected cases, have imposed more workload and distress, respectively…
(Participant #3, Male, JMOH)
…During the COVID-19 pandemic, I am not satisfied with my working conditions, lack of any form of emotional support or even safety incentives, coupled with a low number of healthcare workers, have all led to increased workload on me and my colleagues…
(Participant #2, Female, JMOH)
Theme 3
Impacts of the pandemic on doctor-patient communication and professional skills
During the current pandemic, physicians have experienced a change in the classical doctor-patient communication during the pandemic, and this was an expansion of the predicting factors of job satisfaction that could exhibit a bidirectional effect from the physicians’ perspectives. The COVID-19 pandemic has pushed various sectors to work and communicate remotely through virtual means:
…Using digital platforms for consultation and patient follow up is considered one of the newly emerged communication methods in healthcare practice in Jordan. Healthcare professionals especially doctors were obliged to learn the digital health skills and effectively utilize them amidst the pandemic crisis…
(Participant #1, Male, Private Sector)
On the other hand, a physician has expressed an increase in the level of interaction with patients:
…being a member of the epidemiological surveillance team, my communication with people has significantly increased during the COVID-19 pandemic…
(Participant #4, Female, JMOH)
Physicians had also worrisome concerns about their communication with patients and other professional skills:
“As a pediatrician, there was a noticeable difficulty in communicating with families and following up with my patients and newly discharged neonates and infants using the telephone. There was a lack of clinical examinations and milestones follow-up as this need in-person attendance to the clinic which was impacted by lockdown measures”.
(Participant #2, Male, Private Sector)
Surgeons seemed to be also worried about their surgical skills, two surgeons said:
…I was worried about my surgical skills during the long period of nationwide lockdown in Jordan and any further lockdowns in the future…
(Participant #9, Male, Private Sector)
Another surgeon added:
…Return to surgical practice after long lockdown was challenging, because surgeons rely on daily surgical skills usage. I believe that dealing with surgical operation using a guided step-by-step approach helped me to pass through the challenge of not performing surgical procedures for few months during lockdown in Jordan…
(Participant #1, Male, Private Sector)
Theme 4
The economic impacts of the pandemic crisis and lockdown
Salary is considered an important factor for job satisfaction. In our cross-sectional survey, early-career physicians who had an average monthly income below 700 JDs were found to have lower job satisfaction. No one would deny that the COVID-19 pandemic has negatively impacted the world’s economy. This was partially a result of the lockdown/curfew policy imposed by many countries including Jordan, alongside other control measures. Physicians as part of the society were also vulnerable to suffer from pandemic-induced economic impacts.
A Physician said:
“…The lockdown policy has severely impacted individuals who do not have a stable monthly income such as daily workers. Despite that, there was a sort of community-governmental partnership at the early stages of lockdown in Jordan for supporting individuals with unstable earnings, but this has gradually decreased by time …”
(Participant #2, Male, Private Sector)
Another physician added the following:
…From an economic perspective, I was worried about my financial stability due to lockdown and the governmental decisions to allow the managerial panel of the healthcare sector as well as other sectors in Jordan to deduct from their employees' salaries as per the declared defense law in Jordan...
(Participant #4, Female, JMOH)
Some physicians in the private sector were also impacted financially due to the lockdown policy in Jordan:
…As an owner of a private clinic, and during the pandemic crisis, my financial status has deteriorated due to the lockdown and even after the gradual return to functioning economy. People were hesitant to visit private healthcare institutions due to their financial crisis during the pandemic…
(Participant #10, Male, Private Sector)
I think that the pandemic crisis has already impacted everyone in society economically, even healthcare workers. I have witnessed many cases in which salaries of healthcare workers including medical doctors were partially deducted, especially in the private sector. This has led to negative psychological impacts on us …
(Participant #5, Male, Private Sector)
Despite that many physicians reported higher financial burden due to the pandemic, some physicians have not been financially impacted, considering the healthcare institutions where they work:
“…this pandemic did not afflict my salary as I work at a governmental healthcare institution, thus having a stable monthly income...”
(Participant #3, Male, JMOH)
“During the lockdown in Jordan, I did not feel that there was a direct impact on my monthly income as I have a stable salary every month, however, I noticed that prices of many consumer goods have been raised during the lockdown and curfew…”
(Participant #7, Female, JRMS)
And another physician added:
“…My salary was not affected by the pandemic crisis because I work at a military healthcare institution; thus, having a stable monthly income from the government…”
(Participant #11, Female, JRMS)