Occupational Burnout in Hospitals. A Population-Based Study among Health Professionals Working in Hellenic Red Cross Hospital ()
1. Introduction
An increasing global interest in the study of stress and burnout in professionals resulting from their workplace has been noted recently. In Greece, the associated negative effects have increased lately, and the phenomenon of occupational burnout is one of the factors that threaten the implementation and organizational structure of the provided health service [1] . Employees, who experience stress and burnout, affect their mood changes and attitude the morale of the rest of the staff, and their frequent tardiness and absences negatively affect the delivery of quality care and increase the workload of the staff remaining consistent with their obligations [2] .
Burnout does not appear suddenly. On the contrary, problems gradually worsen. As soon as any employee—in any profession and at any level of work—may be experiencing burnout, it is essential to recognize the symptoms of his exhaustion before they get out of his control. The prolonged work stress leads to the collapse of his adaptive capacity, and eventually, he ends up becoming an exhausted professional, unable to process any of his daily routine tasks, frustrated with himself and his work environment, which finally leads him to isolation and perhaps dismissal from his duties [3] [4] .
Occupational burnout, even though is a widespread subject of research and has been the focus of a rapidly growing interdisciplinary concern, has currently no widely accepted definition [5] . The most cited definition of burnout is that of psychologist Christine Maslach, who named the associated syndrome for the first time [6] . In her definition, she states that the person experiencing a chronic condition, where work requires more than he can give and gives him back less than he needs, makes the person feel tired, despised, worthless and out of control at work. Alongside this constant imbalance, burnout syndrome is set to begin when three conditions co-exist: emotional exhaustion, followed by depersonalization, and when the person becomes aware of his cynicism, he is overwhelmed with feelings of failure and reduced personal achievements [7] . Based on the above, researchers of the burnout phenomenon use Maslach’s Occupational Burnout Inventory as a basis of their work [8] . The cost of burnout consequences seems to be quite large from any field examined (social, economic, individual, etc.) [9] . It is estimated that 3% - 4% on average of the Gross Domestic Product of the countries in the European Union is spent on diseases related to work stress and other related conditions. 50% - 60% of all lost work days in the European Union have been estimated to be somehow related to stress as well as that it costs at least 20 billion euros per year [10] . For these reasons, recently has been a concerted effort at the European Union level for research but also for dealing with burnout syndrome and other related issues.
The aim of our study is to investigate the level of burnout among health professionals in Hellenic Red Cross Hospital. Specifically, the objectives of the present study are:
a) The correlation of professional burnout with their demographic characteristics and specifically age, sex, marital status, years of service, level of education, specialty, and position of responsibility,
b) The study of specific factors of the administrative organization of the hospital and their possible association with burnout, such as the work environment, administrative control, salary, role ambiguity, lack of staff, large number of shifts, etc.
2. Methodology
The present study is cross-sectional in nature, investigating burnout symptoms in the health-related staff who work in Hellenic Red Cross Hospital, which is one of the biggest Public Hospitals in Athens, Greece, by measuring the three dimensions of burnout; emotional exhaustion, depersonalization and personal achievements.
The method used for data collection was to self-complete a questionnaire in written form. The questionnaire was distributed to all health professionals of our hospital, and it was completed by 116 health workers at the time of data collection. Only fully completed questionnaires were included. Before conducting the survey, written permission was requested from the Scientific and Administrative Boards of our institution. The acceptance to complete the questionnaire was considered consent to participate in the study.
2.1. Variables of Interest
The variables investigated in the present study are related to:
a) Demographics of the sample: age, gender, educational level, family status, professional specialty, position of responsibility, years of seniority
b) Administrative factors: work environment, collegial solidarity, support from the supervisor and colleagues, administrative control, remuneration, role ambiguity, lack of staff, large number of shifts, lack of protective measures and stressful work due to the COVID-19 pandemic, etc.
The impact of those variables is investigated in the 3 dimensions of burnout (emotional exhaustion, depersonalization and lack of personal achievement).
2.2. Measuring Tool
An anonymous written questionnaire was used to conduct the study, which consisted of two parts:
a) The first part contained general information related to the demographics of the respondent, such as gender, age, education level, family background and condition, length of service at the hospital, etc.
b) The second part included the Maslach Burnout Inventory (MBI). The Maslach Burnout Inventory is the most commonly used tool to self-assess whether you might be at risk for burnout (Appendix). The MBI consists of 22 questions and measures the three dimensions of burnout syndrome: emotional exhaustion (9 questions), the lack of personal achievements (8 questions) and depersonalization (5 questions). The score is calculated with a 7-point Likert scale ranging from 0 (never) to 6 (every day).
Pearson’s correlations showed that higher levels of burnout were indeed associated with a more frequent experience of symptoms (calculated by averaging answers to the set of questions). General linear models testing gender and occupational role as independent variables and including age and years of profession as covariates were run to assess the presence of significant differences in levels of burnout and experienced symptoms.
3. Results
3.1. Demographic and Occupational Characteristics
The study population included 116 health workers. The demographic characteristics of the study sample are shown in Table 1. The mean age was 39.1 ± 10.3 years and the mean number of years of service was 15.2 ± 10.8 years. The majority of workers were female (84.5%), married/cohabiting (51.7%), working on a rotating schedule (75.9%) and permanent workers (68.1%). 73.3% were nurses, 13.8% were administrative staff, and 12.9% were nursing assistants.
3.2. Maslach Burnout Inventory (MBI)
The Cronbach’s alpha internal consistency coefficient for the emotional exhaustion scale was 0.86, for the depersonalization scale it was 0.74 and for the personal achievement scale, it was 0.77, which indicates very good reliability. The descriptive results for the Maslach scale are presented in Table 2, while in Table 3 the levels of burnout are presented. 50% of workers experienced high emotional exhaustion, 50.9% experienced high depersonalization, and 16.4% experienced mild personal accomplishment.
3.3. Association of Demographic and Occupational Characteristics with Burnout
Table 4 presents the bivariate association of demographic and occupational characteristics with burnout. Multivariate linear regression was performed to neutralize confounders, and the results are presented in Table 5. According to the results of the multivariate linear regression, the following statistically significant relationships emerge: single/divorced/widowed had greater emotional exhaustion and depersonalization than married people, men had more emotional exhaustion and depersonalization than women, and morning workers had more personal accomplishments than shift workers.
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Table 1. Demographic and professional characteristics of the employees.
αmean value, standard deviation.
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Table 2. Descriptive results for the Maslach scale.
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Table 4. Bivariate connection between demographic and occupational characteristics with burnout.
a: control t; β: Pearson correlation coefficient; c: analysis of variance; d: Spearman correlation coefficient.
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Table 5. Multivariate linear regression with burnout as the dependent variable.
4. Discussion
The purpose of the current study is to investigate the level of burnout among health professionals in Hellenic Red Cross Hospital. The overall findings of the study show that people who provide health care services in our hospitals are a vulnerable group to burnout syndrome. It was found that emotional exhaustion moves at medium to high levels, as did depersonalization, while personal achievements are at moderate to low levels (Table 5).
According to Olley [11] , nurses belong to the most vulnerable group of health professionals in terms of the occurrence of occupational burnout syndrome. Stress at work affects job satisfaction and by extension contributes to the manifestation of burnout. Among the factors that particularly produce stress to nurses is the work in shifts and particularly working night shifts. Night work is blamed for a multitude of organic and psychiatric disorders to such an extent that more daylight work is recommended as part of the treatment [12] [13] . Prospects in professional development, good cooperation with colleagues and essential support from their superiors, and support from their family are very important parameters for the satisfaction of nurses and limit the occurrence of professional burnout. The positive attitude of the superior and support from colleagues seems to play a particularly important role, as it reduces work stress and increases work efficiency and satisfaction and limits the chances of burnout syndrome [14] .
In the sample of the present study, which concerns mainly nurses in the health field, was highlighted that the quality of the provided service is affected by the educational category of the health professional. According to Coffey [15] and Olafson et al. [16] , the quality of the provided service is related to the energy one gives during work, and exhausted workers—especially nurses—often shows reluctance to take over duties, indifference and apathy towards the patient and his relatives, lack of disposition for social contacts, etc. Demir et al. [2] in their research found that experience at work, higher educational level and higher position in the hierarchy reduce burnout, while working in shifts increases it. Working conditions, along with understaffing and grueling shifts promote the occurrence of burnout in nurses. It is a common finding that the fiscal policy that is applied has an important impact on the occurrence of burnout in many areas of life. Low income is related to all three dimensions of burnout, emotional exhaustion, lack of personal achievement and depersonalization. According to one assessment, perhaps this attitude results from the fact that workers believe they are being paid less than they are worth.
After the study of demographic characteristics on burnout, older nurses and those with more years of service showed higher levels of feeling a lack of personal achievement and smaller rates of emotional exhaustion and depersonalization. The most vulnerable age group is workers between 36 - 45 years old. A possible explanation for this is that older workers typically have more years in the profession and have developed automation in the ability to understand how their patients feel. Therefore, they manage their patients’ problems more effectively more mechanistically and more calmly and this positively affects their lives in general when they deal effectively with the problems that arise in their work. Younger nurses showed lower levels of burnout because of the higher degree of ambition, goals and dreams. On the other hand, burnout evolves progressively and cumulatively, and older nurses who are in the profession have developed better strategies for regulating their emotions and solving their problems. Also, older ones have redefined their goals and remain in the profession with a conscious and mature outlook.
Married nurses (without children) experienced less emotional exhaustion in the present study. This is perhaps associated with the fact that married people, as well as nurses, report more satisfaction with their work. On the other hand, married people with children showed higher rates of depersonalization. One possible explanation is that married people are less committed to their work compared to single people, who invest more in it, because married people also have responsibilities in their role as spouses and parents, which according to Chiriboga & Bailey [17] , is significantly related to higher levels of burnout. Divorced people are also a vulnerable group to develop professional burnout. Family/work conflict has been of considerable concern to researchers. According to Yildirim & Aycan [18] , it appears that there is a relation between family obligations, which make it difficult to be dedicated to work, and vice versa.
Regarding gender, in the sample of the present study, we found a statistically significant difference in two of the three causative factors of burnout between male and female nurses: emotional exhaustion and depersonalization. This finding does not contradict Maslach, who argues that gender constitutes one of the demographic factors related to professional burnout. In addition, he argues that the differences between the two sexes are related to the predetermined nature of some occupations as male or female. Gender affects to a certain extent, the way of looking at life in general and managing stressful situations, which may or may not be effective. Also, women employed in health professions experience higher levels of anxiety and depressive disorders, with the frequency of suicides being twice that of men and six times that of the general population [19] . Female nurses have a higher incidence of anxiety disorders, as was shown in a study in Greek hospitals.
In a study by Yaktin [20] , it was found that the higher hierarchical position held by a nurse (supervisor, shift manager) leads to greater job satisfaction. The nurses without a position of responsibility are related to higher levels of depersonalization. According to the British psychoanalyst Chernis [21] , depersonalization is a process of abdication of the employee resulting from stress, pressure and fatigue that he experiences, and represents a feedback mechanism of individual freedom. Higher educational levels, emotional support from colleagues and more years of service seem to limit the likelihood of the syndrome to occur. Higher emotional exhaustion and higher sense of personal achievements of university graduates, in contrast to low depersonalization, showed that health professionals of this category experience difficulties with the working environment and workload. It highlights also the importance of continuing education in health professionals as a method to reduce occupational burnout.
There are certain limitations that are related to the heterogeneity of our sample. The majority of the health professionals examined were female (84.5%), working on a rotating schedule (75.9%) and with permanent positions in their working environment (68.1%). Most of them were nurses (73.3%) and nursing assistants (12.9%), and fewer were administrative staff (13.8%). Burnout in physicians of our hospital wasn’t examined, leaving a large percentage of health professionals without investigation. There are many studies that utilize Maslach Burnout Inventory (MBI) to examine occupational burnout, and therefore a consensus on the methodology seems to be established. More studies, with larger study samples and greater diversity, will guide us to safer conclusions and will offer solutions that will ease the financial burden of occupational burnout in hospitals.
5. Conclusions
The conclusions drawn from the present study showed that nurses who represented the main group of our study, experience more intense signs of emotional exhaustion, and there is a correlation between work and personal achievements. Nurses strongly display the feeling of lack of personal achievements because they experience unpleasant working conditions to a greater degree, and they are, therefore, more prone to developing burnout syndrome. Gender, marital status, academic education and years of service are related to emotional exhaustion. Female sex, divorced, and lower academic-level nurses show more emotional exhaustion. Working in shifts, work environment, role ambiguity, salary, relationships with colleagues, but also family obligations, are also factors that are related to occupational burnout. The lack of support from superiors as well as non-emotional support from their colleagues, are linked to the dimension of emotional exhaustion.
The findings of the present study indicate that emphasis should be given on increasing the personal achievements of employees, and reducing emotional exhaustion and depersonalization. To achieve the above, measures should be taken at an individual level by every employee, such as reassessing personal goals and expectations, seeking support, and finding space and time to “decompress” between work and home. Interventions such as encouragement to recovering should be implemented, democratic management and participation of employees in decision-making, working under supervision and psychological support, diversity in the working environment, continuing education and training, etc.
Perhaps a future more detailed study around this topic that would include health professionals from every field would enlighten us about the causes and treatment of burnout syndrome in health professionals working in hospitals.
Funding Statement
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Ethics Approval Statement
Institutional Review Board/Independent Ethics Committee (IRB/IEC) of Korgialenio-Benakio Red Cross Hospital, Athens, Greece. Ref. No.21976/7.9.2022 (included in the supplemental material).
Contributorship Statement
Konstantinos G. Seretis analyzed the results and wrote the manuscript, Maria-Theodora Papa collected the data and analyzed the results, Anastasia Tsakalaki collected the data, Constantine N. Antonopoulos revised the draft, Maria Kostorrizou collected the data, Maria Ompasi collected the data, Sofia Tzamtzidou collected the data, and Theofanis Papas designed the study and revised the draft.
Burnout Self-Test Maslach Burnout Inventory (MBI)
For each question, indicate the score that corresponds to your response. Add up your score for each section and compare your results with the scoring results interpretation at the bottom of this document.
Scoring Results—Interpretation
Section A: Burnout
Burnout (or depressive anxiety syndrome): Testifies to fatigue at the very idea of work, chronic fatigue, trouble sleeping, physical problems. For the MBI, as well as for most authors, “exhaustion would be the key component of the syndrome.” Unlike depression, the problems disappear outside work.
• Total 17 or less: Low-level burnout;
• Total between 18 and 29 inclusive: Moderate burnout;
• Total over 30: High-level burnout.
Section B: Depersonalization
“Depersonalization” (or loss of empathy): Rather a “dehumanization” in interpersonal relations. The notion of detachment is excessive, leading to cynicism with negative attitudes with regard to patients or colleagues, feeling of guilt, avoidance of social contacts and withdrawing into oneself. The professional blocks the empathy he can show to his patients and/or colleagues.
• Total 5 or less: Low-level burnout;
• Total between 6 and 11 inclusive: Moderate burnout;
• Total of 12 and greater: High-level burnout.
Section C: Personal Achievement
The reduction of personal achievement: The individual assesses himself negatively, feels he is unable to move the situation forward. This component represents the demotivating effects of a difficult, repetitive situation leading to failure despite efforts. The person begins to doubt his genuine abilities to accomplish things. This aspect is a consequence of the first two.
• Total 33 or less: High-level burnout;
• Total between 34 and 39 inclusive: Moderate burnout;
• Total greater than 40: Low-level burnout.