Exploring Early Detection and Support for Burnout Among Primary Healthcare Registered Nurses in a District Based in Gauteng Province, South Africa

1. Introduction

Burnout is broadly understood as a psychological state of exhaustion resulting from chronic work-place stressors in the absence of sufficient coping resources [1]. It is defined as a syndrome with three interrelated components: exhaustion, cynicism (or depersonalization), and reduced professional efficacy [1,2]. RNs experiencing burnout lose interest in their work, and their work becomes increasingly unmanageable and unsustainable.

Globally, RNs face a significant risk of burnout due to high workloads, emotional demands, and workplace stressors. In New Zealand, for example, more than half of the surveyed RNs reported intentions to leave the profession or reduce their hours due to burnout, with workplace factors, particularly workload intensity, being cited as the main cause [4]. To maintain safe staffing levels, New Zealand requires an additional 4,800 RNs immediately, with shortages projected to reach 8,000 by 2032 [4]. Similar challenges are observed internationally, where ageing populations and the growing burden of chronic diseases continue to intensify demands on healthcare systems [4]. These trends suggest that burnout is not only a local problem but a global challenge affecting healthcare delivery.

A growing body of research has explored interventions to mitigate burnout, emphasizing the importance of organisational support, adequate staffing, and access to workplace resources [5]. While high job demands contribute significantly to burnout, the availability of job resources such as managerial support, professional development, and peer networks has been shown to improve engagement and job satisfaction. However, the effectiveness of such support systems varies across healthcare settings.

Empirical studies highlight the extent of burnout among RNs.For instance, a cross-sectional study that was conducted in Saudi Arabia, among 161 primary healthcare nurses in the Qassim region, revealed a high prevalence of burnout risk (78.9%), with emotional exhaustion present in 35.4%, depersonalization in 44.7%, and low personal accomplishment in 57.8% of participants [6]. These findings underline the crucial need for targeted interventions, such as mindfulness-based stress reduction, peer support sessions, team-building activities, burnout education and workshops, to promote self-care practices and avoid burnout among RNs in PHC.

Generally, studies from New Zealand, Saudi Arabia, and Africa [1,4,5,6] illustrated that RNs’ burnout is a prevalent and common issue influenced by global and local factors. While circumstantial challenges differ, common ones consist of high workloads, emotional demands, insufficient resources, and the importance of supportive workplace environments in sustaining RNs’ well-being and healthcare delivery.

In South Africa, RNs face more problems that consist of poor human and material resources, a lack of medical equipment, increased patient loads, and systemic pressures within the healthcare system. These challenges intensify the physical, psychological, and emotional manifestations of burnout and negatively affect nurses’ well-being, professional relationships, teamwork, and compromised quality of care to patients [1].

Burnout is acknowledged by the World Health Organization (WHO) as a syndrome caused by chronic workplace stress that is not managed; it is not classified as a medical condition but rather as an occupational phenomenon [7]. Worldwide, there are no accepted diagnostic criteria; hence the Netherlands has established its national guidelines for assessing burnout [8,9]. The guidelines provide an initial assessment of risk, guiding referrals for further evaluation and support, which may include employee assistance programs or other relevant services [9]. This indicates the important role that self-report tools play in detecting and managing burnout timeously.

Burnout among RNs has become a critical concern globally due to its impact on workforce well-being, patient care, and healthcare efficiency [10]. RNs are particularly vulnerable because of high workloads, staff shortages, long shifts, and emotionally demanding work. Evidence from high-income countries indicates that burnout varies by specialty, with primary care professionals facing a higher risk [11]. At the International Workforce Forum of the International Council of Nurses (ICN), nursing leaders emphasized the need for safe staffing levels, decent working conditions, and retention strategies to prevent the loss of experienced nurses who are vital for high-quality patient care and the education of future healthcare professionals [12].

The imbalance between job demands and available resources underlies the etiology of burnout [13]. High job demands, such as excessive workload and work pressure, lead to emotional exhaustion and burnout, whereas adequate job resources protect health, stimulate personal growth, and enhance engagement and job satisfaction [14].

Understanding the early detection of burnout and the availability of support systems for RNs working in PHC facilities is necessary for improving effective approaches to prevent and mitigate its impact. Personal and social coping mechanisms, organizational support systems, and employee-assisted programs (EAPs) play a critical role in assisting RNs to manage stress and maintain well-being. The study aimed to explore early detection of burnout and the availability of support systems for registered nurses working in primary healthcare facilities in a district based in Gauteng Province, South Africa. It is anticipated that the findings will highlight gaps in current support mechanisms and inform strategies to strengthen RNs’ well-being and improve the quality of patient care.

2. Materials and methods

2.1. Type of Study

This study employed a qualitative, exploratory design to examine the lived experiences of burnout among RNs in a District Based in Gauteng Province, South Africa. An exploratory study is ideal for investigating complex, subjective experiences, as it seeks to capture the essence of participants’ perceptions, emotions [15], and interpretations of burnout. This design allowed the researcher to explore not only what registered nurses experience but also how they make sense of these experiences within their work and organizational contexts [16].

2.2. Population and Sample Size

The study population comprised seventeen (17) RNs currently working in PHC facilities in a District in Gauteng Province, SA, employed full-time, and with more than two years of service. RNs with direct experience of work-related stress and burnout, who were willing to share their experiences, were included. A purposeful sampling strategy was used to recruit registered nurses who have worked in a (PHC) setting for more than two years and are registered with the South African Nursing Council. Semi-structured face-to-face interviews were conducted with seventeen (17) registered nurses (RNs). Data saturation was achieved after the twelfth (12th) interview, when no new themes or patterns emerged; however, data collection continued until the seventeenth (17th) interview to ensure thorough coverage of the phenomenon.

2.3. Recruitment Process

Following ethical clearance from both the university and the Health District, the researcher scheduled appointments with facility managers to explain the study’s aims and objectives. The facility managers provided guidance on appropriate times to conduct interviews and assisted in identifying potential participants who met the inclusion criteria. Potential participants were approached at their respective healthcare facilities, with approval from facility managers and district management. The purpose of the study was explained clearly to each prospective participant, and written informed consent was obtained before participation.

2.4. Study Context

The study was conducted in a district in Gauteng Province, South Africa. The district is the most densely populated in Gauteng, with seventy-seven primary health care facilities and sixteen mobile clinics that serve the far-to-reach communities and the informal settlements. The PHC facilities operate from 08:00 t0 16:30 hours Monday to Friday. The PHC facilities provide comprehensive services, including maternal health services, HIV/AIDS/TB and STI, curative services, and chronic Services.

2.5. Interview Guide

A semi-structured interview guide was used to gather data for the study. The interview guide was informed, adapted from the Maslach Burnout Inventory (MBI), and formulated based on related literature. Four participants were used as a pre-test before the main data collection started, and the results were not included in the overall data. This was conducted to improve the depth of the data collected. Modification of the interview guide was done accordingly, following the findings from the pre-test study. This included minor changes regarding how questions can be phrased based on the answers from RNs who were in the pilot study. An outline of the interview guide is attached as Annexure A.

2.6. Data Collection Procedure

Data was collected by using a semi-structured interview guide to ensure that the data collected is comprehensive and insightful [16], and face-to-face interviews were conducted in private consulting rooms to ensure confidentiality. Interviews were scheduled either before nurses began their clinical duties or after consultations, depending on participants’ availability. The researcher requested approximately 30–45 minutes of the participants’ time for each interview. Only the researchers and the participants were present during the interview to ensure privacy and encourage open discussion.

Before the interviews, participants were fully informed about the study procedures, including audio recording of the sessions, and their demographic details, such as age, gender, years of service, and role, were collected. The interview guide was divided into several sections to gain a thorough understanding of nurses’ experiences with burnout. Section A covered demographic information and rapport-building, asking participants about their professional background, including how long they had been registered nurses and their years of experience in primary healthcare. Section B examined participants’ understanding of burnout and early detection, prompting descriptions of emotional, psychological, and physical signs, barriers to early recognition, facilitators of detection, and their perceptions of workplace support. Section C focused on burnout symptoms, contributing factors like workload and organizational pressures, and the effects on work relationships, including teamwork and communication. Section D addressed coping strategies and available support mechanisms, including formal support (e.g., EAP and counseling), informal support (e.g., colleagues), and personal strategies, along with participants’ suggestions for improving support. Section E invited final thoughts and practical recommendations for reducing burnout. With participants’ consent, interviews were audio-recorded and transcribed verbatim, and observations and field notes were recorded to supplement the interview data.

2.7. Coding and Data Analysis

Data analysis involves the process of organizing and reducing data to extract meaningful insights [17]. After data collection, the audio-recorded interviews were transcribed. Additionally, notes taken during and after the interviews were typed and compiled. The researcher transcribed the interviews verbatim in English from the audio tapes. The transcripts were carefully reviewed and compared with the audio recordings to verify data accuracy. All transcripts were thoroughly examined and cross-checked against the recordings. The transcribed data underwent thematic analysis following the six steps outlined in [18]: data familiarization, coding, initial theme generation, reviewing and developing themes, refining, defining, and naming themes, and writing up. The transcripts were then shared with an independent coder experienced in qualitative research for coding. The researcher and the independent coder discussed the themes and categories to reach an agreement, ensuring both parties concurred on the final themes and categories. All transcripts and notes were imported into NVivo 15 software for systematic coding, organization, and thematic analysis. Raw demographic data were summarized using Microsoft Excel.

2.8. Ethical Considerations

Ethical approval from the Ethics Committee of Sefako Makgatho Health Sciences University (SMUREC), protocol number SMUREC/452/2024:PG, was obtained before data collection. The researcher also asked for permission to conduct the study from the District Health Research Committee and the PHC facility Managers. securing written informed consent from participants after providing full information about the study’s purpose, procedures, risks, and benefits; ensuring confidentiality by anonymizing participants’ identities and securely storing data accessible only to the research team; upholding participants’ right to withdraw at any time without consequences; providing emotional support through referrals for counseling or psychological assistance if participation evoked distress; and maintaining rigor and trustworthiness through credibility, transferability, dependability, and confirmability [19] using techniques such as prolonged engagement, member checking, audit trails, and reflexive journaling.

3. Results

Participants in this study included n=14 RNs from PHC clinics in a District Based in Gauteng Province, South Africa. The participants’ mean age was 42.86 years (SD = 7.40). Among the participants, four (4) were registered nurses with primary healthcare (PHC), nine (8) were registered nurses with midwifery, community, and psychiatric specialties, and three (2) were registered nurses with midwifery. Participants’ ages ranged from 25 to 59 years, with 4 to 30 years of work experience. There were eleven females and six males. Participants’ years of experience as registered nurses ranged from 4 to 30 years, with a mean of 14.43 years (SD = 7.42). Emerged themes and Sub-themes are in Table 1.

Theme 1: Manifestations of Burnout Among Registered Nurses

This theme shows how burnout manifests both physically and psychologically in registered nurses. It involves exhaustion, detachment, and demotivation that impact their well-being and job performance. Participants described experiencing both physical and mental exhaustion, which were clear signs of burnout. Physical and emotional tiredness, along with symptoms like irritability, sadness, and hopelessness, were commonly reported. Additionally, physical symptoms such as headaches, fatigue, and body pain, combined with sick leave, often resulted in absences. Some participants also described depersonalization and emotional disconnection, feeling detached from patients and colleagues, and functioning “like robots.” Feelings of helplessness and demotivation underscored the deep emotional toll burnout took on their professional and personal lives. Overall, these findings demonstrate the extensive impact of burnout on registered nurses’ health, morale, and productivity.

Physical and Psychological Exhaustion

The key manifestations of burnout are physical and mental exhaustion; the qualitative interviews showed that RNs often experience both. Constant fatigue, sleep problems, and physical illnesses, along with feelings of being exhausted, irritable, and having difficulty focusing explained by participants. Their personal well-being and work performance were connected to high patient loads and the emotional toll of caring for patients, demonstrating how exhaustion can harm both physical and psychological health. Participants highlighted that exhaustion impacted their physical stamina and emotional health. One participant reflected:

“Even on my off days, I feel too tired to recover.”

(Identified as P2 47 yrs, M,10 YOE)

And continues to say:

“Burnout is that state where you feel tired; you can’t even wake up in the morning. Even your weekends do not solve anything because you’re always tired, and your mind is tired.”

“Even if you can get that weekend off, but still on Monday, you come back up with that tiredness.”

“I’m not saying that maybe people don’t have problems; they do have problems, but if you see problems like this week, next week, and every time, then you know that people are tired, yes, yes, and our clinic is very, very, very, very busy and always full, and we are short-staffed, so you can see that everyone is tired; we get tired, and we don’t have enough rest.”

“I did, because as I’m saying that, at times I do have those moments where you just get tired every day, you feel like you did not sleep at night, and you wake up tired, so I do have it.”

“Burnout is when you are exhausted. It’s a stage where you feel tired; you can’t even wake up in the morning. Umm, you cannot solve anything because your body is always tired. Your mind is just tired. Even if you can get that weekend off on Monday, you still come back with that tiredness.”

(Identified as P9,38yrs, F,11 YOE)

“Burnout, I don’t know how to put it, but it is when a person is drained, emotionally, and tired at the same time. I feel sick, because tomorrow, I will wake up very tired, and I feel I cannot wake up. I cannot even cope.”

(Identified as P11,59yrs, F,30 YOE)

Physical Symptoms and Sick Leave

Physical symptoms such as fatigue, low energy, weight gain, and general malaise linked to burnout were reported by participants. These symptoms often lead to frequent sick leave and high absenteeism among registered nurses. While not always formally diagnosed, these issues reflected the emotional and physical toll of burnout. RNs believed that their troubles were ignored by management, emphasizing a sense of helplessness and frustration as per the quotes below:

“Sometimes I take sick days just to rest mentally because we are always fighting each other, and most of the time they are off sick.”

(Identified as P11,59yrs, F,30 YOE)

Another participant added by saying that:

“You know, you start feeling sick. Well, I can’t say sick as such, but you feel, I don’t know, I can say I even gained weight because now you’re anxious. Now you eat, now you, you know?”

(Identified as P4,33 yrs, M,4 YOE)

Further added that: 

“I was not sick, but I could not get the energy to come to work. I went to see the doctor and told him I’m tired. Even if we speak, there are no actions that are being taken. There’s nothing that’s going to happen, just take your time off and go and get a sick note.”

Depersonalization and Emotional Detachment

Participants described feeling emotionally numb, disconnected from their patients and colleagues, and lacking the passion or empathy that once motivated their work. Burnout caused a sense of operating on autopilot, fulfilling duties out of obligation rather than genuine care. Many RNs admitted to feeling like “zombies,” emotionally detached, and just going through the motions. This detachment not only impacted patient care but also undermined team cohesion and morale, according to the following quotes:

Participants revealed feelings of emotional detachment or numbness, as illustrated in the following quotations:

(Identified as P12,42 yrs, F,14 YOE)

“Ohhh yeah, you don’t even have the patience to help your patients, but you just dream and are forced to do it. “I am working for the sake of working. I am no more empathetic.”

(Identified as P3,41 yrs, F,13 YOE)

“I think I did; I do know what burnout is, and it is not a nice feeling, it is like you are a ‘zombie’you are not yourself”.

(Identified as P4,33 yrs, M,4 YOE) elaborates:

“We need support in all spheres of work because we are working for the sake of working”.

Researcher reflected -So you are emotionally detached from your patients.

(Identified as P4,33 yrs, M,4 YOE)

“YES, I feel detached from my colleagues. It is like ‘everybody for himself and God for us, you know, we don’t take care of each other.”

(Identified as P7 .43 yrs, F,17, YOE) also indicated that: 

“Like I said, besides the quality of the nursing, which I would give. You drag yourself going to work, and you find yourself counting hours until I can knock off. What time is lunch? When should I just stop working? You’re just going to work for the sake of being present at work. But your passion and your worth and your ethics are not there anymore. Those are just a few things or qualities that I’ve noticed”.

Theme 2: Factors Contributing to Burnout Among PHC RNs

Major contributing factors to burnout, including a variety of workplace and organizational challenges, were identified. RNs constantly emphasized that workload and high patient ratio, and staff shortages were among the major contributors to burnout. Lack of consumables and medical equipment impeded the ability to provide quality care, especially when combined with the need for multitasking under stressful conditions, further increasing pressure. Limited organizational support, along with poor collaboration and lack of teamwork, aggravated feelings of neglect and frustration as they felt that they were being exploited, portraying situations where management expected them to “push through “even though they felt RNs experience challenges in accessing or using the EAP, and this results in receiving help very late. These factors accentuate systemic failures that uphold burnout in the healthcare environment.

Workload and Staff Shortages

From the data collected, the participants expressed their concern about inadequate staffing, which leads to increased workload for the existing staff. They continually cited an unsustainable workload, sometimes exceeding 90 patients per day, with RNs adopting numerous roles beyond their scope. Severe and chronic understaffing and lack of equipment further increased stress levels, often skipping breaks and lunch, leading to emotional and physical weakening. This strain directly impacted on the quality of life and patient care. This was expressed by the participants below:

“When the clinic is very full, and there is a shortage of staff, and many patients are flocking to the emergency room, you leave them and attend to the emergency. They wait for a long period, waiting for us to come back from the emergency room, like yesterday, I worked alone, Nobody. We are not paid overtime, and everybody left me alone with the patients”.

(Identified as P7,43 yrs, F,17, YOE)

Another participant shared the same sentiment by alluding to that by saying:

“Our clinic is very, very, very busy. It’s always full, and we are short-staffed, so you can see that everyone is tired. Concerning our work, yes, sometimes we do get training. It’s work, but now the thing is. Due to staff shortages, we are unable to attend all the training as scheduled, and we miss a lot of training because we need to just push the queues.

“Yes, opportunities are there, but we miss them. Because the biggest thing is the staff shortage. In a day, you will end up doing three, sometimes more, services, right? And remember, first, it is a high-volume facility.

(Identified as P8,40 yrs, M,9 YOE)

In a clinic were, maybe for Ante Natal Clinic (ANC), a system would see maybe only 10 patients. (See, now our maximum is like 60, sometimes more, depending on the day. So now, you are already tired from all those patients that you’ve seen. “Everyone knows that the health system is currently failing because we don’t have enough staff. We understand that they’re talking about budget and all that, but the problem is we need staff regardless of whether we have this budget or not. Right now, our pharmacy assistant passed away 6 months ago, so I am the one who manages the pharmacy. I am responsible for receiving and managing drugs. We don’t have a clinic manager; we are rotating to act as clinic managers.” (Identified as P1,39 yrs, F,10 YOE)

(Identified as P1,39 yrs, F,10 YOE)

Insufficient consumables, equipment, and inadequate teamwork.

The effects of burnout extended beyond individual experiences to the broader workplace environment. Participants reported that burnout frequently compromised work relationships and teamwork, resulting in tension among colleagues, reduced communication, and diminished trust. This breakdown in collaboration not only affected the morale of staff but also had potential implications for patient care quality and safety. Participants indicated that burnout negatively affected relationships with colleagues, undermining teamwork and collaboration in the workplace. There were frequent reports of misunderstanding, reduced team cohesion, and conflict among participants, which resulted in increased irritability, emotional withdrawal, and interpersonal tension.

“We are at loggerheads with each other; there are so many complaints coming from our patients; there is a waiting time because we are short-staffed and facing insults from patients; we are going through a tough time.”

(Identified as P2,47 yrs, M,12 YOE)

“At some stage, I did feel alone, even though I would talk with my colleagues. But the thing is, when talking to your colleagues, they would change the whole thing that you’re saying. So, at some stage, yes, I did feel alone. Okay. Yeah, I did.”

(Identified as P3,41 yrs, F,13 YOE)

“It’s even worse now, because with this burnout, we are fighting amongst ourselves. Because it’s like, if I am to take a day, I’m sick with whatever. Other people feel some type of way, like, why are you sick when we are short-staffed already? So, it’s like, no, we’re not supported”.

(Identified as P4,33 yrs, M,4 YOE)

“I noticed them being burned out; yeah, from time to time, they share their feelings that I have also had. They have a negative attitude towards their patients.”

“As I said, yes, I am pushing the queue; there is only quantity of work, not quality.”

Participants admitted that burnout strained teamwork and reduced cooperation. Some confessed, “We snap at each other more often; everyone is tense.”

“Because, like I say, even now, it’s affecting our team morale.”

“It’s like CJ (pseudo name); at this point, we don’t even get along anymore, because we’re fighting about things we have no control over.”

“Mm, laughing. I think so. I know that because most of the time they snap at patients, they are irritable and short-tempered.

(Identified as P1 (39 yrs, F,10 YOE)

Challenges to Access or Use EAP

Participants support structured and ongoing mental health interventions and encourage the use of Employee Assistance or Wellness Programs (EAPs).

“If you get emotional support, a lot of counseling... support that you can get.”

(Identified as P3,41 yrs, F,13 YOE)

However, P9 refers to EAP-type programs as a helpful yet underutilized resource.

(Identified as P9 ,38yrs, F,11 YOE)

“Maybe if we can get counseling... employee wellness... that can help us.”

The participant acknowledges counseling as valuable but calls for deeper engagement. EAPs must be well-targeted.

(Identified as P3,41 yrs, F,13 YOE)

Participants acknowledge counseling as valuable but call for deeper engagement. EAPs must be well-targeted. There will be a positive outcome when EAP-like services are accessed.

“I can go for counseling... but if I have not dealt with the core. I got the first experience of our psychiatric counseling... they were very helpful, and they did encourage a whole lot of resting and taking time off.”

(Identified as (P3,41 yrs, F,13 YOE)

Theme 3- Barriers to Early Detection of Burnout Among PHC RNs

Burnout is repeatedly underrecognized and poorly understood among RNs, as revealed by a study. Some participants demonstrated inadequate awareness and knowledge of burnout, often misattributing its symptoms to routine fatigue, continuing to work through their health challenges, reflecting a workplace culture that discourages rest and self-care, even though they had obvious signs of psychological and physical exhaustion. Some participants described a normalization of burnout symptoms, minimizing their severity or viewing them as an unavoidable aspect of nursing. This normalization of distress does not delay early identification and intervention.

Lack of Awareness and Knowledge of Burnout

Limited awareness and knowledge about burnout, its symptoms, and coping strategies stalled early identification and effective management, were reported by participants. RNs indicated that they do not fully understand the signs of burnout in themselves or colleagues, which caused the delayed intervention and increased stress.

“People don’t realize that they are burned out… they just use words like ‘I’m tired’.”“I didn’t realize that this is burnout.

(Identified as P1,39 yrs, F,10 YOE)

Work Continues Despite Health Challenges

Despite experiencing emotional exhaustion or distress, many nurses continue their duties without adequate support. This ongoing performance under strain reflects a culture that prioritizes service delivery over individual well-being.

“It’s like you’re on your own. See, if patients are being seen, and the day is over, it’s like no one cares.”

P10 (46 yrs, M,19 YOE)

“I had to combine my patient and hers, so I had to go home after 18h00, no managers came to assist me... I was never paid the overtime that I worked for.”

(Identified as P1,39 yrs, F,10 YOE)

Normalization of Burnout Symptoms

RNs accepted fatigue, stress, and emotional exhaustion as an expected part of the job to normalize burnout in their workplace. This normalization discouraged help-seeking behaviors and led to continued exposure to stressors without intervention. Fatigue and emotional exhaustion have become routine experiences, often normalized to the point that they are no longer seen as warning signs of burnout.

“I think you tell yourself that you are coping right, you’re so used to this pattern of working everywhere not focusing on your work working with more patients than that you’re supposed to be working with yeah so you think that you are coping and at the end of the day you can feel that’s been no this is not normal yeah you are tired now when it catches up with you that’s when you realize that,, no no you’re not coping yeah you’ve been out this is been hectic. That is why it is difficult to see that we are burning out. We have normalized the abuse by the system.”

(Identified as P12,42 yrs, F,14 YOE)

Theme -4. Strategies to Cope with Burnout Among PHC RNs

Participants recommended that mental check-ins and emotional support from colleagues or professionals are valuable and should be standardized. They stressed the significance of mental health check-ins as positive measures to identify early signs of burnout and support RNs’ well-being. These initiatives were identified as necessary for timely intervention, stress reduction, and a healthier work environment.

Organisational Interventions and Support

Insufficient organizational support significantly contributed to burnout, according to participants who stressed the value of organizational interventions and support in preventing and managing burnout. Measures that were mentioned included EAP, structured debriefing, adequate staffing, and recognition of efforts. These strategies were thought to be necessary and important to improve resilience, job satisfaction, and well-being of RNs; the quotes below indicate the feelings of RNs:

“Maybe I can call my manager or, you know, yeah, it should not be like a bad thing”.

“Okay. So, it’s more on the work culture that it shouldn’t be okay for you to tell managers, to tell your colleagues, so that you can get the support that you need”.

(Identified as P2,47 yrs, M,12 YOE)

“I think confidentiality and, um, like I said, if we were to have an openness, if we were able to be open with our immediate supervisors, be able to talk to them, and, um, if they don’t have, you know, that judgmental phase. So, I think if we can get it right with our immediate managers, then we can be able to be better. And know that whatever I say will not go to the next person, because as soon as it leaks out to another person, it’s out.

(Identified as P 43 yrs, F,17 YOE).

“Burnout requires a lot of resting, and most of our nurses do not take advantage, make use of their annual leave or even sick days to go and, and rest enough so that they can come back with much energy to continue giving quality work. So, I think that HR should then come and encourage Nurses to take their leave days so that they can take some rest and then come back reenergized.”

(Identified as P6,37 yrs, F,12 YOE).

“If maybe we can just get the support. I don’t know. Yeah, if maybe we can get the support, I think maybe we can be okay.”

Limited managerial guidance, lack of recognition, inadequate staffing, and scarce resources are some of the factors that left RNs feeling unsupported, undervalued, and overwhelmed. Lack of organized support mechanisms made it challenging to cope with both the physical and emotional demands of their roles. Participants felt unsupported by management, and others suggested that supervisors failed to recognize burnout as a serious issue.

“Not at all, we hardly see managers from big offices visiting us. Nobody cares about us; we are being dumped. We have raised concerns, but no one cares about that, so you feel that even for me to say that I’ve got this thing that’s going to help me was going to help you.”

(Identified as P8,40 yrs, M,9 YOE)

“We hardly see managers from the corporate office coming here; the only time you see them is when there is a complaint from a patient, then you will see them. We are on our own; no one came to our rescue.”

(Identified as P3,41 yrs, F,13 YOE)

Burnout Awareness Training and Peer Support

Participants emphasized the importance of burnout awareness training as a preventative strategy to recognize early signs of stress and exhaustion. Such training was seen as crucial for equipping nurses with knowledge, coping strategies, and tools to manage burnout effectively, both for themselves and their colleagues. Participants indicated the need for capacitation of registered nurses as outlined in the following quotes:

“ Maybe there should be road shows and workshops to empower nurses on burnout.”

(Identified as P2 (47 yrs, M,12 YOE)

“I think with the in-services that we get, wellness should also be part of it.”

(Identified as P3 (41 yrs, F,13 YOE)

The quotes below collectively highlight the urgent need for a systematic, confidential, and proactive burnout screening tool. Such a tool would help detect early signs of burnout, normalize mental health check-ins, reduce stigma, and promote timely interventions without relying solely on self-reporting. This quote strongly suggests the lack of a formal mechanism for detecting burnout. Participants often mistake burnout for general fatigue, indicating a need for structured awareness or screening methods such as regular self-assessments or organizational screening tools. Currently, signs of burnout often go unnoticed or are recognized too late due to the lack of systematic monitoring or evaluation tools. These quotes emphasize the importance of routine assessment processes to identify and address burnout before it worsens.

Quotes Suggesting the Need for a Screening Tool.

“I think we do; we just don’t access it. And as I said, we also have the stigma thing, because I know there’s a wellness employee, what, what?”

(Identified as P3 (41 yrs, F,13 YOE)

The participant is aware of available support but hesitates to access it due to stigma. A standardized, non-stigmatizing screening tool could facilitate identification and referrals without requiring self-disclosure.

“You’re scared... maybe they want to meet with you... You must arrange, maybe with your clinical manager... So, you’d rather keep it to yourself.”

(Identified as P1 (39 yrs, F,10 YOE)

The fear of being exposed or judged indicates the need for a confidential, anonymous screening mechanism to detect emotional distress early.

“Even though the services are there, I can’t say, today I need to go to wellness. What about your patients? Who’s going to see your patients?”

(Identified as P11 59 yrs, F,30 YOE)

Highlights the absence of routine wellness checks or assessments, further suggesting the value of an embedded screening tool that doesn’t require self-initiation.

“We hardly see managers from the corporate office... only when there is a complaint from a patient...”

(Identified as P8,40 yrs, M,9 YOE)

This reactive approach to issues implies a lack of proactive systems, such as screening tools, to regularly assess staff well-being.

Personal Coping Strategies

Participants reported using various personal coping strategies to manage the stress and demands of their work. These strategies included time management, relaxation techniques, exercise, reflective practices, and seeking social support. Such approaches helped nurses maintain their well-being and continue providing quality care despite challenging work conditions. Participants emphasized that support from colleagues played a crucial role in coping with burnout. Emotional encouragement, teamwork, and guidance helped mitigate stress, improve resilience, and foster a sense of belonging in the workplace.

(Identified as P1,39 yrs, F,10 YOE)

“ Using alcohol just to cope. Because at the end of the day, I’m tired.

(Identified as P8,40 yrs, M,9 YOE)

“I’m not sure, but if there’s I’m not sure if they are effective because when I’m not at work, I don’t think about the problems of work. OK, yeah, so just when I’m off work, I don’t think about work. I just listen to music when I get home, and I watch movies with my family.”

“I would say yes, time off is fine, but, um, the problem also must find out what the problem is because we can’t just get time off and you still can’t work, and the problem is still there”.

“My colleagues provide psychological and mental support amongst themselves, Ike I said earlier, being burned out doesn’t only involve the physical aspect, but also the emotional and mental. We help with the workload and see how we can reduce the workload to prevent or lessen the burnout.

(Identified as P7,43 yrs, F,17, YOE)

4. Discussions

The study aimed to explore Early Detection and Support for Burnout Among Primary Healthcare Registered Nurses in a District Based in Gauteng Province, South Africa, in relation to existing literature. Seventeen interviews were conducted, and data saturation was achieved at interview twelve. The discussion is presented according to the four major themes that emerged from the data.

Our study discovered that RNs experienced substantial physical and psychological exhaustion, including fatigue, sleep disturbances, anxiety, irritability, and emotional instability. These findings support earlier research showing that burnout presents both physical and psychological symptoms and often develops progressively [20]. In other studies, [21,22] similar reports indicated that long working hours and chronic stress contributed to serious exhaustion in RNs, which supports participants’ narratives of being mentally overwhelmed and physically drained.

Our study further revealed that participants use coping mechanisms to protect themselves from emotional overload by resorting to depersonalization and emotional detachment. This mirrors the descriptions of emotional distancing outlined by other researchers [23], who noted that depersonalization often emerges in high-pressure healthcare environments. The steady shift from empathy to detachment detected in this study supports the patterns emphasized in the research [24], which argues that continued stress contributes to reduced professional fulfillment. Increased sick leave and demotivation [25] were reported by RNs in this study, which confirms that burnout leads to absenteeism, reduced morale, and lower productivity [26]. It is evident that burnout is associated with frequent sick leave episodes, according to the experiences of RNs in this study.

A central finding was that workload pressures and critical staff shortages intensified burnout. Participants reported caring for more patients than they could safely manage, often performing duties beyond their scope. This is consistent with research by [27] showing that poor staffing ratios increase burnout risk. Comparable findings indicated that inadequate staffing was a major source of workplace stress among frontline healthcare workers [28].

According to the findings of this study, resource constraints, poor teamwork, which significantly contributed to frustration and emotional stress, were also contributory factors to burnout, as felt unsupported by management, as there are limited medical supplies, equipment shortages, and inadequate collaboration, and this created an environment where they felt left alone or neglected.

These findings align with the researcher [29], who emphasized that poor communication and poor teamwork between RNs and management cause psychological distress. Dysfunctional workplace dynamics negatively impact team morale 30] and job satisfaction. Furthermore, RNs indicated that there is limited access to support programs such as the Employee Wellness Program, despite its availability. This aligns with this study [31], which identified limited use of mental health services due to perceived stigma and structural barriers. [32] Also noted that organizational support exists in policy but remains inaccessible in practice.

The findings revealed that a lack of burnout education prevents early recognition and intervention. Participants noted that they received no formal training on burnout detection. The observations by other researchers [33,34] highlighted that insufficient professional training perpetuates poor awareness of burnout symptoms, which aligns with the results of this study. The need for education to promote early identification of stress-related disorders among RNs was emphasized [17].

Normalization of burnout symptoms, where RNs perceived ongoing fatigue, stress, and emotional strain as “part of the job,” was a very disturbing finding. This phenomenon has also been noted by the researcher [35], who indicated that normalization contributes to delayed help-seeking and chronic burnout. Further discovered that RNs often minimize their symptoms to meet workplace demands [36], highlighting the pattern seen in this study.

Additionally, RNs fear burdening colleagues and continue working despite serious health issues, motivated by a sense of duty and altruism. This behavior reflects findings by [37], who observed that healthcare professionals often kept working through burnout because of ethical obligations. [38] It is noted that dedication to patient care often takes precedence over personal health concerns. There is an urgent need for stronger organizational interventions, including mental health support, adequate staffing, better resource availability, and accessible counseling services, based on our study’s findings. These results support those of [17], who argue that systemic solutions, rather than solely individual coping strategies, are necessary to effectively combat burnout. Both personal and organizational interventions have been demonstrated to reduce stress and enhance job satisfaction [39].

Participants supported burnout awareness training and screening programs to enable early detection. This aligns with international guidelines cited in [7] and research presented in [24], both of which emphasize the importance of routine screening to detect burnout before it leads to significant impairment. Regardless of the challenges that RNs are facing, they rely on personal coping strategies and peer support, such as prayer, exercise, journaling, and teamwork. These findings are consistent with the coping mechanisms identified by [40], who stressed the importance of emotional support networks in managing workplace stress.

The results and findings of this study suggest that burnout among RNs is an outcome of a combination of issues, including personal fatigue, systemic issues, limited awareness, and lack of organizational support. The results strongly align with existing research, confirming that burnout in nursing is a universal challenge that needs both individual, organizational, and policy solutions. Improving early detection, enhancing workplace conditions, and increasing access to mental health resources are essential for supporting the well-being of primary healthcare nurses in South Africa.

4.1. Limitations of the Study

While the study offers valuable insights, it has numerous limitations: the geographic scope was confined to the Ekurhuleni district, potentially limiting applicability to other regions; self-reported data may introduce bias, affecting responses to sensitive issues like mental health; and the cross-sectional design restricts findings to a single time point, necessitating longitudinal studies for understanding long-term trends in RNs’ burnout and intervention effects.

4.2. Recommendations

A multi-level approach is required to decrease burnout among RNs, comprising individual, organizational, and policy interventions. Independently, RNs should engage in self-assessment for burnout, take part in education and workshops, leverage peer support, seek help proactively, and undergo training in stress management. Organizationally, supportive work environments should be established through mental health check-ins, workload redistribution, empathetic leadership, and recognition of staff contributions. Policy measures need to include integrating burnout prevention into health strategies, implementing standardized screening protocols, and ensuring funding for wellness initiatives. These joined efforts aim to improve early detection, prevention, and support for nurses’ well-being, encouraging workforce resilience and better healthcare delivery.

4.3. Strengths of the Study

Despite its limitations, the study on burnout among registered nurses in PHC settings shows notable strengths, including its contextual relevance, rigorous qualitative analysis, and the development of a burnout self-screening tool. By achieving thematic depth, it uncovers key patterns in nurses’ experiences and systemic challenges. Additionally, the study’s holistic perspective incorporates personal, organizational, and policy dimensions, allowing for targeted recommendations that could enhance nurse well-being and strengthen the healthcare system.

5. Conclusions

This study explores burnout among RNs in a District Based in Gauteng Province, South Africa, revealing it as a significant issue often mistaken for general fatigue. Symptoms include emotional and physical exhaustion and decreased care quality, exacerbated by inadequate training, lack of screening tools, and a focus on tasks over staff welfare. Many RNs are unaware of existing support mechanisms like Employee Assistance Programs (EAP). The study calls for a comprehensive intervention approach at individual, organizational, and policy levels to address burnout, emphasizing the need for structural changes and support systems to improve RNs’ well-being and the quality of patient care. It advocates for recognizing the value of nurses and investing in their mental health, underlining the broader benefits for healthcare systems and society.

Burnout among PHC RNs is multi-dimensional, arising from the interaction of individual traits, work demands, organizational culture, and systemic resource constraints. While personal coping and social support provide temporary relief, long-term solutions require organizational commitment, structural improvements, and supportive policies. These findings provide evidence-based guidance for designing interventions that tackle burnout at both the individual and organizational levels.