Edwin Lugazia

Background: Traditional occupational health models rely on simple binary classifications “burned out” versus “healthy” that mask the transitional phases of distress through which clinicians pass before reaching complete collapse. In resource-constrained acute care environments across sub-Saharan Africa, severe emotional exhaustion often represents a systemic baseline rather than an individual anomaly. This study moves beyond the burnout binary to identify multi-dimensional latent distress profiles and model the specific tipping points and biological pathways that drive overextended but empathy-preserved clinicians into complete clinical burnout. Methods: We conducted a secondary analysis of a cross-sectional dataset (N=135) capturing emergency medicine, anesthesia, and intensive care clinicians at Muhimbili National Hospital in Dar es Salaam, Tanzania. Using the Maslach Burnout Inventory-Human Services Survey (MBI-HSS), we categorized clinicians into five mutually exclusive latent profiles. Multivariable logistic regression identified independent tipping points for progression from isolated exhaustion to full burnout. Mediation analysis (Hayes PROCESS Macro, Model 4) examined the pathway through which extended shifts associate with burnout. Ethical clearance was obtained from the Muhimbili University of Health and Allied Sciences Research and Publication Committee (Ref. No. MUHAS-REC-6-2020-290), and all participants provided written informed consent. Results: Among 135 clinicians, 62.2% (n=84) met criteria for Fully Burned Out (high exhaustion, high cynicism, low personal accomplishment), 28.1% (n=38) were Overextended (isolated high exhaustion with preserved empathy and efficacy), and 9.6% (n=13) experienced Disengaged/Moderate Strain . Notably, 0.0% (n=0) met the criteria for the Resilient/Engaged profile. Within the exhausted cohort (n=122), multivariable modeling identified shift durations exceeding 12 hours (AOR 8.72, 95% CI [1.24, 61.15], p=0.012), poor coworker relationships (AOR 4.11, 95% CI [1.42, 11.90], p=0.009), sleep deprivation under 6 hours (AOR 4.25, 95% CI [1.74, 10.40], p=0.001), and lack of regular exercise (AOR 3.10, 95% CI [1.25, 7.68], p=0.015) as independent tipping points of collapse. Mediation analysis demonstrated that the link between extended shifts and burnout was fully mediated by sleep degradation (indirect effect ab=0.264, 95% CI [0.114, 0.458]). Conclusions: In low-resource acute care settings, emotional exhaustion is a universal baseline (90.4%) driven by severe systemic constraints rather than a failure of individual grit. The complete absence of a resilient cohort challenges the prevailing individual-level resilience paradigm. Drawing on the African philosophy of Ubuntu “I am because we are” this study demonstrates that collective team solidarity serves as the single strongest protective buffer against clinical collapse. Preventing clinical collapse requires structural policy shifts: capping shifts at 12 hours to protect biological rest, actively cultivating team solidarity as a workplace safety net, and investing in cadre-specific interventions that recognize the distinct vulnerabilities of nursing staff and trainees, who bear 80.9% of the burnout burden despite comprising 73.4% of the workforce.

Background: Strengthening health systems through planned safety and quality improvement initiatives is an imperative to achieve more equitable, resilient, and effective care. And yet, years of organizational behavior research demonstrate that change initiatives often fall short because managers fail to account for organizational readiness for change. This finding remains true especially among surgical safety and quality improvement initiatives in low-income countries and middle-income countries. In this study, our aim was to psychometrically assess the construct validity and internal consistency of the Safe Surgery Organizational Readiness Tool (SSORT), a short survey tool designed to provide change leaders with insight into facility infrastructure that supports learning and readiness to undertake change. Materials and methods: To demonstrate generalizability and achieve a large sample size (n=1706) to conduct exploratory factor analysis (EFA) and confirmatory factor analysis (CFA), a collaboration between seven surgical and anesthesia safety and quality improvement initiatives was formed. Collected survey data from health care workers were divided into pilot, exploration, and confirmation samples. The pilot sample was used to assess feasibility. The exploration sample was used to conduct EFA, while the confirmation sample was used to conduct CFA. Factor internal consistency was assessed using Cronbach’s alpha coefficient. Results: Results of the EFA retained 9 of the 16 proposed factors associated with readiness to change. CFA results of the identified 9 factor model, measured by 28 survey items, demonstrated excellent fit to data. These factors (appropriateness, resistance to change, team efficacy, team learning orientation, team valence, communication about change, learning environment, vision for sustainability, and facility capacity) were also found to be internally consistent. Conclusion: Our findings suggest that communication, team learning, and supportive environment are components of change readiness that can be reliably measured prior to implementation of projects that promote surgical safety and quality improvement in low-income countries and middle-income countries. Future research can link performance on identified factors to outcomes that matter most to patients.

Efforts from the developed world to improve surgical, anesthesia and obstetric care in low- and middle-income countries have evolved from a primarily volunteer mission trip model to a sustainable health system strengthening approach as private and public stakeholders recognize the enormous health toll and financial burden of surgical disease. The National Surgical, Obstetric and Anesthesia Plan (NSOAP) has been developed as a policy strategy for countries to address, in part, the health burden of diseases amenable to surgical care, but these plans have not developed in isolation. The NSOAP has become a phenomenon of globalization as a broad range of partners – individuals and institutions – help in both NSOAP formulation, implementation and financing. As the nexus between policy and action in the field of global surgery, the NSOAP reflects a special commitment by state actors to make progress on global goals such as Universal Health Coverage and the United Nations Sustainable Development Goals. This requires a continued global commitment involving genuine partnerships that embrace the collective strengths of both national and global actors to deliver sustained, safe and affordable high-quality surgical care for all poor, rural and marginalized people.

Critical care saves lives of the young with reversible disease. Little is known about critical care services in low-income countries. In a setting with a shortage of doctors the actions of the nurse bedside are likely to have a major impact on the outcome of critically ill patients with rapidly changing physiology. Identification of severely deranged vital signs and subsequent treatment modifications are the basis of modern routines in critical care, for example goal directed therapy and rapid response teams. This study assesses how often severely deranged vital signs trigger an acute treatment modification on an Intensive Care Unit (ICU) in Tanzania. A medical records based, observational study. Vital signs (conscious level, respiratory rate, oxygen saturation, heart rate and systolic blood pressure) were collected as repeated point prevalences three times per day in a 1-month period for all adult patients on the ICU. Severely deranged vital signs were identified and treatment modifications within 1 h were noted. Of 615 vital signs studied, 126 (18%) were severely deranged. An acute treatment modification was in total indicated in 53 situations and was carried out three times (6%) (2/32 for hypotension, 0/8 for tachypnoea, 1/6 for tachycardia, 0/4 for unconsciousness and 0/3 for hypoxia). This study suggests that severely deranged vital signs are common and infrequently lead to acute treatment modifications on an ICU in a low-income country. There may be potential to improve outcome if nurses are guided to administer acute treatment modifications by using a vital sign directed approach. A prospective study of a vital sign directed therapy protocol is underway.

While there is a need for good quality care for patients with serious reversible disease in all countries in the world, Emergency and Critical Care tends to be one of the weakest parts of health systems in low-income countries. We assessed the structure and availability of resources for Emergency and Critical Care in Tanzania in order to identify the priorities for improving care in this neglected specialty.