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JOURNAL OF PREVENTIVE MEDICINE AND HYGIENE 2000; 41: 18-23

Use of the Maslach Burnout Inventory to support Health Care Workers management in hospital

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S. BRUSAFERRO*, A.P. AGNOLETTO*, F. GUBIAN*, M. BALESTRIERI** Chair of Hygiene and Epidemiology, Department of Experimental and Clinical Pathology and Medicine, University of Udine; ** Chair of Psychiatry, Department of Experimental and Clinical Pathology and Medicine, University of Udine

Key words Burnout · Management personnel · Quality

Summary

Introduction The object was to evaluate, as a quality indicator, the presence of burnout syndrome among Health Care Workers (HCWs) operating in clinical wards in a 304 beds University Hospital in Italy in order to improve personnel management policy within the frame of a hospital quality plan. Methods In July 1998 we sent a self administered anonymous questionnaire (July 1998) to all HCWs (doctors, nurses, ancillary staff) operating in medical and surgical wards. The questionnaire included questions related to demographic and occupational aspects and the Maslach Burnout Inventory (MBI) modified for Italian Health Service workers. Results We had a 78.9% (308/390) response rate with no statistically significant differences for sex, age, professional qualification

among clinical wards. We identified n.31 workers in burnout (10.1%). Burnout resulted, both in univariate and multivariate analysis, related to serious personal experiences lived in the three months before the study (OR 1.6 - 95%C.I. 1.0-2.5) and to working in wards like Neurology (OR 3.5 - 95%C.I. 1.3-9.2) and Intensive Care Unit (OR 3.2 - 95%C.I. 1.2-8). Low levels of personal achievement resulted associated with being a female (p < 0.05) and being an ancillary worker (p < 0.05). Conclusions HCWs burnout is an important indicator that determines hospital output quality. Our data, that partially differ from literature, confirm the utility for hospital managers to have a updated map about the presence of burnout syndrome in their hospitals. If implemented periodically it would help to define personnel management strategies and policies, to empower personnel, to improve quality and to measure their effectiveness.

Introduction

The concept of «stress» in the work place has a great importance in health care settings. Most research in this field, conducted by psychologists and psychotherapists, has focused attention on testing/validating instruments, analysing specific health care settings or at risk categories, but rarely evaluating management perspectives 1. Health Care Workers (HCWs) are considered an at-risk category for that syndrome, particularly those dealing with people suffering from serious illnesses and those exposed to a high death rates among patients 2-4 . HCWs hospital management uses many different indicators to survey stress levels: absenteeism rate 5, number of applications for removal 6, HCWs turnover among wards 7 8, etc. However these are «proxy» indicators of stress, while the burnout presence is more specific. Burnout is a term frequently used to describe the experience of HCWs dealing with stressful situations, and it is defined as a multiple syndrome constituted by three aspects very relevant in hospital management as well as for preventive medicine 9: emotional exhaustion, depersonalisation and lack of personal achievement 10. Possible burnout causes are present in situations like lack of resources (workload), lack of technical ability,

insufficient training, difficulty to cope with patient problems, existing barriers in the organisation 2 7. Most of these causes are related to management aspects. Burnout syndrome can cause a general decrease of work quality and can be associated to important psychological effects, including depression, anxiety, conflicts with colleagues, indifference and cynicism with patients, increasing alcohol/drugs intake, family strain, relationship breakdown and increased irritability 11. We used the presence of burnout syndrome as an indicator of HCWs management quality in a University Hospital in order to improve personnel management policy within the frame of a hospital quality plan.

Methods

We adopted a self administered anonymous questionnaire to HCWs (doctors, nurses, ancillary staff) operating in the medical and surgical wards in a north eastern Italian University Hospital. The wards included were Neurology, Dermatology, Haematology, Orthopaedics, Paediatrics, Urology, Obstetrics and Gynaecology, Internal Medicine, Intensive Care Unit, General Surgery and Plastic Surgery. Questionnaires were administered in July 1998; a letter accompanying the questionnaire informed the partici-

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USE OF THE MASLACH BURNOUT INVENTORY TO SUPPORT HEALTH CARE...

Tab. I. Subscales values modified in the Italian adaptation of MBI.

bles we used multiple logistic regression model. A p value of 0.05 was accepted as statistically significant.

MBI subscales

Range of experienced burnout Low Moderate 15-23 4-8 30-36 High > 23 >8 < 30

Results

We had a global response rate of 78.9% (308/390). Among clinical wards there were no statistically significant differences for sex, age, professional qualification. The ratio n°HCW/n° beds ranged from 1.0 in ObsGyn, to 1.3 in Orthopaedics, to 1.4 in General Surgery, Internal Medicine, Neurology, Others, to 1.6 in Haematology, to 7.75 in ICU (Anaesthesiology operating theatres personnel included). We confirmed the correlation between subscales and items reported in the MBI manual (high levels of emotional exhaustion and item number 8, depersonalisation and items number 10 and 11). These data allows us to confront our results with the literature. According to our definition of «burned out subject» we identified n. 31 workers in burnout (10.1%). Characteristics of the population are reported in Table II, which shows the distribution of «burned-out subjects» by different variables. Burnout was statistically related (p < 0.05) to serious personal experiences lived in the three months before the study and to working in wards like Neurology and Intensive Care Unit (p < 0.01). In these wards we did not find differences by professional category. Table III shows the values distribution in our population with respect to the three burnout subscales. 11% of the respondents revealed high levels on each of the subscales; 55-60% of the respondents showed low levels of emotional exhaustion and depersonalisation, while 68.3% was satisfied with his job. We analysed possible correlation between subscales and single variables: emotional exhaustion correlates with the presence of a serious personal situation (p < 0.05); low levels of personal achievement with being a female (p < 0.05) and being an ancillary worker (p < 0.05). To control for non-independent effects of these variables on burnout levels we used multiple logistic regression models. Table IV shows the Odds Ratio (OR) in the different models studied and this analysis confirms previous results. Although not statistically significant both the presence of a serious personal situation in the last three months and the condition of widowed/divorced showed an increased risk, in the models, to develop the burnout syndrome.

Emotional Exaustion Depersonalization Personal Achievement

< 15 <4 > 36

pants that the study was attempting to gather information about the situation in Health Care Wards. The first part of the questionnaire investigated the following variables: sex, age, marital status, number of children living at home, education, professional activity, employment period in Health Services, employment period in the University Hospital, night-shifts. We also investigated if the respondent had been living through hardship (i.e. divorce, serious diseases, end of a personal relationship) in the last three months. This question was added to include also personal situations that could influence burnout levels. The second part of the questionnaire included the Maslach Burnout Inventory (MBI) modified for Italian Health Service workers 10. The MBI is a 22-items questionnaire designed by Maslach and Jackson to assess the three aspects of burnout syndrome: emotional exhaustion, depersonalisation and lack of personal achievement. Separate subscales measure these aspects. «Emotional exhaustion» encompasses those feelings that result from depletion of emotional resources. «Depersonalisation» measures impersonal and uncaring attitude. The «personal accomplishment» subscale assesses feelings of competence and successful achievement in one's work with people. The Italian version differed from the original one, because there is only one subscale for feeling frequency, and feeling intensity is not tested because of a high correlation between these two aspects. Table I shows the classification of MBI validated values in the Italian version. Burnout is conceptualised as a continuous variable ranging from low, to moderate, to high degrees of experienced feelings. It is not viewed as a dichotomous variable that is either present or absent. A high degree of burnout is correlated with high scores on emotional exhaustion and depersonalisation while inversely correlated with personal accomplishment. We defined, in accordance to the literature 12, «burned-out subjects» those who presented at least two subscales out of three in the high range. We aggregated wards with burnout levels < 5% (Dermatology, Urology, Plastic Surgery and Paediatrics) in a single category defined «others». Data were analysed with SPSS 7.0; for statistical analysis we used Fisher's exact test, Chi-square test and Spearman's analysis. To control for confounding varia-

Discussion

The burnout in health care settings is one of the problem that organisations have to cope with. Previous studies on burnout in hospital have focused their attention on specific organisational aspects: on single wards, particularly mental health units 13 14, oncology units 15 16, hospices 17; on single professional categories, more often nurses 2 7 13 18 but also physicians 3;

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Tab. II. Respondents characteristics and burnout distribution.

respondents (tot. n. 308) n. sex male female n.r. < 30 30-39 40-49 50 + n.r. single married divorced/ widowed n.r. 0 1 2 3 n.r. compulsory school high school university degree n.r. ancillary workers nurses doctors n.r. yes no n.r. < 10 10-19 20 + n.r. yes no n.r. Ost.Gyn Int.Medicine Gen. Surgery Int.Care Unit Neurology Orthopaedic Haematology others 70 236 2 107 120 65 13 3 148 143 16 % 23 77 1 35 39 21 4 1 49 46 5

burnout distribution characteristics tot. burnout respondents n. 69 232 7 105 118 64 13 8 147 139 16 4 187 56 45 8 12 84 146 70 8 57 182 58 11 189 109 11 187 70 39 13 55 223 30 49 29 51 26 21 22 28 77 4 27 11 14 6 0 15 11 4

p

% 5.8 11.6 10.5 11.9 9.4 0 10.2 7.9 25 n.s.

age (years)

n.s.

marital status

n.s.

n.dependent children

educational qualification

188 57 48 8 7 85 149 71 3 59 184 59 6 192 109 5 190 71 40 7 55 228 25 50 29 52 26 23 22 28 78

60 19 116 3 2 28 48 23 1 19 60 19 2 62 36 2 62 23 13 2 17.9 74 8.1 16.2 9.4 16.9 8.4 7.5 7.1 9.1 25.3

19 4 6 1 10 16 5

10.2 7.1 13.3 12.5 11.9 11 7.1

n.s.

n.s.

profession

8 17 4 17 12 19 10 1 10 15 5 5 3 6 6 2 2 2

14 9.3 6.9 9 11 10.2 14.3 2.6 18.2 6.7 10.2 17.2 5.9 23.1 28.6 9.1 7.1 2.6

n.s.

night shifts

n.s.

years in health services serious personal situation wards

n.s.

< 0.05

< 0.01

n.r. = no response

on single aspects of the problem: shifts rotation 7, resources constraints 19, etc. Different studies examined this topic through different approaches, using different scales 16 17 19-21; MBI is one of the most utilised.

So far there is a lack of longitudinal studies showing the long term effects of specific interventions in preventing burnout in hospitals but a representation of the burnout distribution is a great opportunity for hospital managers in different ways:

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USE OF THE MASLACH BURNOUT INVENTORY TO SUPPORT HEALTH CARE...

Tab. III. values distribution through the three MBI subscales.

MBI subscale Low % Emotional exhaustion Depersonalisation Personal achievement 55.8% 59.7 68.3

Range of experienced burnout Moderate n. % 76 75 60 25.1% 24.8 19.8

High n. 58 47 36 % 11.1% 11.5 11.9

1. it allows a comparative analysis within the hospital, reducing numerous confusing factors; the comparison between hospitals which have different organisations, different cultures, different case-mix is difficult; 2. it identifies, in the specific context, wards at greater risk and it helps to plan preventive interventions; 3. it contributes to prevent professional accidents related with stress 22; 4. it reduces losses due to low quality performances and diminished quantity production 19; 5. it could be viewed, as well as hospital infections 1, as a quality indicator for the hospital organisation. MBI in our experience gave a preliminary evaluation as a part of a hospital quality project. HCWs perceived quality is a decisive aspect because it determines hospital output quality 1. The interaction and the empathy between HCWs and patients are decisive both in the

clinical results and in the patient's perception 19. An HCW with high levels of personal achievement and low levels of depersonalisation and emotional exhaustion is prone to be empathic and supportive to the patients 23. One possible problem of our study could be the limited number of subjects for single ward, which did not allow to reach statistically significant values in some analysis. With this limitation in mind, we observed a global dimension of burnout levels under the expected values. Only in few wards levels were comparable to those of the literature 3. This phenomenon could be partially explained by the characteristics of the hospital, where most of the activity is scheduled and where only few patients are accepted on emergency basis. In our study Neurology and Intensive Care wards had an high burnout level without differences by professio-

Tab. IV. Multivariate analysis of the risk factors for burnout syndrome.

variables OR wards Ost.Gyn Int. Medicine Gen. Surgery Int. Care Unit Neurology Orthopaedic Haematology Others serious personal situation 1.6 0.7 0.9 0.5 3.2 3.5 1.1 0.8 1

1st model 95% CI OR

2nd model 95% CI

0.2-2.2 0.2-3.4 0.1-1.8 1.2-8 1.3-9.2 0.3-4.2 0.2-3.1

0.8 1 0.5 3.6 3.5 0.6 0.9 1

0.2-2.5 0.2-3.8 0.1-2.1 1.4-9.4 1.3-9.6 0.1-4.1 0.2-3.6

1.0-2.5

1.5

0.9-2.4

marital status divorced/widow married single 1.9 0.5 1 0.7-5.2 0.2-1.1

CI: Confidence Intervals

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nal category. The percentage of the positives in Intensive Care wards is close to the values reported in the literature 3 24, while this consideration is not completely true for the Neurology ward. Others units, like Internal Medicine, showed high percentages of burnout levels (about 17%) but when we included serious personal situations in the model the risk lost significance. In Neurology and Internal Medicine wards, that are not commonly defined as high risk units, we did not expect differences because of the characteristics of the patients treated; their case mix was similar to other university hospitals and probably they had some internal transient situation responsible for the stress. Usually Haematology wards are considered at risk for the syndrome development both for the severity of illnesses and the kind of patients 4 25. Our study showed different results. We found low burnout levels probably because of some already present structured interventions recognised as effective: group approaches have been regularly made to discuss emotional aspects of caring for patients as well as regularly conducted practical case supervision 15 16. In our point of view these discrepancies confirm the utility for hospital managers to have a periodically updated map about the presence of burnout syndrome in their hospitals. Interestingly the presence of a serious personal situation experienced in the previous three months was confirmed to be an important risk factor and we think that this data must be included in management's personnel strategies because of the implications on the workers and on the work quality. The founded correlation between low levels of personal

achievement and professional qualification gives us a hint in modelling our organisation taking account of a particular category (ancillary workers). Causes of work stress can be multiple: institutional, personal and professional. Our study suggests the necessity to plan, in our hospital, structured interventions to deal with some of these risks for the development of burnout syndrome. Different and integrative methods of approach may be considered: good supervisory support, discussion groups, work organisation with duty diversification, working with clear aims, promoting participation in formulating rules 18. In the end some authors suggest the necessity of a Psychiatric Clinical Nurse Specialist (PCNS) not to lose excellent nurses, to improve quality of care, job satisfaction, to increase productivity and to reduce costs 24.

Conclusions

This experience shows that, with few resources, it is possible to implement, on a hospital basis, MBI as an instrument for personnel management in the perspective of the health structures accreditation. If implemented periodically it would help to define personnel management strategies and policies, to measure their effectiveness, to empower personnel, to improve quality and it would permit to improve knowledge on preventing strategies. Because of the evidence of the impact of re-engineering and cost reduction strategies on quality assistance 19 , this approach seems to be useful particularly where a restructuring phase of the Health System or of a single hospital is ongoing.

References

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Pedrabissi L, Santinello M. Quando la socializzazione lavorativa fallisce: lo sviluppo del burnout nei primi sei mesi di lavoro. Risorsa Uomo 1993;2:59-82. 13 Alexander JA, Lichtenstein R, Oh HJ, et al. A causal model of voluntary turnover among nursing personnel in long term psychiatric settings. Res Nurs Health 1998;21:415-27. 14 Prosser D, Johnson S, Kuipers E, et al. Perceived sources of work stress and satisfaction among hospital and community mental health staff, and their relation to mental health, burnout and job satisfaction. J Psychosom Res 1997;43:51-9. 15 Kurshnir T, Rabin S, Azulai S. A descriptive study of stress management in a group of paediatric oncology nurses. Cancer Nurs 1997;20:414-21. 16 Reid Y, Johnson S, Morant N, et al. Improving support for mental health staff: a qualitative study. Soc Psychiatr Epidemiol 1999;34:309-15. 17 Brenner PR. Managing patients and families at the ending of life: hospice assumptions, structures, and practice in response to staff stress. Cancer Invest 1997;15:257-64. 18 Pope E, Nel E, Poggenpoel M. The experience of registered nurses nursing in the general adult intensive care unit. A phenomenological qualitative research study. Curationis 1998;21:32-8. 19 Woodward CA, Shannon HS, Cunningham C, et al. The impact of re-engineering and other cost reduction strategies on the staff of a large teaching hospital: a longitudinal study. Med Care 1999;37:556-69. 20 Hansson UW, Hallberg IR, Axelsson K. Nurses' satisfaction with

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nursing care and work at three care units for severely demented people (see comments). J Psychiatr Ment Health Nurs 1995;2:151-8. Jenkins H, Allen C. The relationship between staff burnout/distress and interactions with residents in two residential home for holder people. Int J Geriatr Psychiatry 1998;13:466-72. Gobbato F. Il medico del lavoro. Compiti e competenze. A.S. Macor editori 1995.

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Leiter MP, Harvie P, Frizzell C. The correspondents of patient satisfaction and nurse burnout. Soc Sci Med 1998;47:1611-7. Zotti AM, Ragazzoni P, Tinelli G. Valutazione dello stress e del potenziale umano per l'organizzazione del lavoro. Le collane della Fondazione Salvatore Maugeri. I Documenti 1998;15. Costantini A, Solano L, Di Napoli R, et al. Relationship between hardiness and risk of burnout in a sample of 92 nurses working in Oncology and AIDS Wards. Psychother Psychosom 1997;66:78-82.

Correspondence: Dr. S. Brusaferro, Department of Experimental and Clinical Pathology and Medicine, Via Colugna 40, 33100, Udine (Italy).

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