1 ιεπιστηµονική Φροντίδα Υγείας(2012) Τόµος 4,Τεύχος 2, ISSN Η Επαγγελµατική Εξουθένωση σε είγµα Ελλήνων Φυσικοθεραπευτών Τραγέα Π. 1, αµίγος. 2, Μαυρέας Β. 3, Γκούβα Μ Φυσικοθεραπεύτρια, MSc Αντιµετώπισης του Πόνου 2.Ψυχολόγος, MSc, PhD, Επίκουρος Καθηγητής Ιατρικής Ψυχολογίας, Ιατρική Σχολή Πανεπιστηµίου Ιωαννίνων 3. Ψυχίατρος, Καθηγητής Ψυχιατρικής, Ιατρική Σχολή Πανεπιστηµίου Ιωαννίνων 4. Ψυχολόγος, MSc, PhD, Επίκουρος Καθηγήτρια, Τµήµα Νοσηλευτικής, ΤΕΙ Ηπείρου ΠΕΡΙΛΗΨΗ Υπόβαθρο: Η επαγγελµατική Εξουθένωση είναι ένα ψυχοκοινωνικό σύνδροµο, που ορίζεται ως µια κατάσταση σωµατικής, συναισθηµατικής και ψυχικής εξάντλησης, η οποία εµφανίζεται σε άτοµα που εργάζονται σε µεγάλα περιβάλλοντα εργασίας, ιδιαίτερα στις αναπτυγµένες κοινωνίες. Μέθοδος: Για τη διεξαγωγή της παρούσας µελέτης, ορίστηκε η αξιολόγηση φυσικοθεραπευτών που θα εργάζονται σε δηµόσια, ιδιωτικά νοσοκοµεία και κέντρα αποκατάστασης στο νοµό Αττικής, κατά το χρονικό διάστηµα εκέµβριος 2009 Μάιος του Με τυχαία δειγµατοληψία, 176 φυσιοθεραπευτές συµπλήρωσαν ανώνυµο ερωτηµατολόγιο, το οποίο εκτός της κλίµακας MBI, περιελάµβανε ερωτήσεις που αφορούσαν σε κοινωνικοδηµογραφικά στοιχεία καθώς και ερωτήσεις που σχετίζονται µε την επαγγελµατική τους ανάπτυξη. Αποτελέσµατα: Ο παράγοντας που επηρεάζει περισσότερο την επαγγελµατική εξέλιξη των φυσιοθεραπευτών του δείγµατος ήταν το µορφωτικό επίπεδο, µε ποσοστό 65,1% και η προσωπικότητα µε ποσοστό 62,9%. Από το σύνολο των συµµετεχόντων, το 52% έδειξε χαµηλή συναισθηµατική εξάντληση, το 45,3% µέτρια έλλειψη προσωπικής εκπλήρωσης - προσωπικών επιτευγµάτων και το 49,1% χαµηλή αποπροσωποποίηση. Με την πολυπαραγοντική γραµµική εξάρτηση διαπιστώθηκε ότι παράγοντες κινδύνου είναι α) το φύλο για τη συναισθηµατική εξάντληση (p = 0,037) και β) η ηλικία για την έλλειψη προσωπικής εκπλήρωσης - προσωπικών (p=0,003). Συµπεράσµατα: Η επαγγελµατική εξουθένωση είναι ένα κοινό πρόβληµα στους φυσιοθεραπευτές του δείγµατος. Περαιτέρω έρευνα απαιτείται προκειµένου να ληφθούν τα κατάλληλα µέτρα όχι µόνο για την αναγνώριση αυτού του φαινοµένου, αλλά και για την πρόληψη και αποτελεσµατική αντιµετώπιση. Λέξεις-Κλειδιά: Επαγγελµατική Εξουθένωση, Φυσικοθεραπευτές, Επαγγελµατίες Υγείας, Ψυχολογία Υπέυθ. Αλ/φίας : Μ. Γκούβα,,ΤΕΙ Ηπείρου, 4o Klm Ε Ο Ιωαννίνων-Αθηνών Ιωάννινα. 77
2 Interscientific Health Care (2012) Vol 4, Issue 2, ISSN Burn out among Greek physical therapists Tragea P. 1, Damigos D. 2, Mavreas V. 3, Gouva M. 4 1.Physiotherapist MSc, «Pain Management» 2.BScPsych, MSc, PhD, Assistant Professor of Medical Psychology University of Ioannina - Medical School, Greece. 3.Professor of Psychiatry, Department of Internal Medicine, Medical School, University of Ioannina, Greece. 4.BScPsych, MSc, PhD, Assistant Professor of Nursing Department, Higher Technological Educational Institution of Epirus, Greece. ABSTRACT Background: Burnout is a psychosocial syndrome, defined as a state of physical, emotional and mental exhaustion, which occurs between individuals working in a vast working environment, especially in developed societies. Methods: For the conduct of the current study, there was appointed the evaluation of physiotherapists working in public and private hospitals, as well as rehabilitation centers in the area of Athens. With the use of random (multi)layered sampling, 176 physiotherapists filled an anonymous questionnaire, which included various subjects concerning burnout; the MBI scale, questions concerning, gender, age, marital status, educational level, professionals sector, as well as questions concerning the factors related to professional development. Results: The factor which influences more the professional development of the participants was the educational level with a 65,1% percentage followed by the personality of the participants with a 62,9% percentage. The prevalence of the burnout was the following; Of the total of the participants,52% showed low emotional exhaustion, 45,3% medium personal achievements and 49,1% low depersonalization. Age group correlated with PA mean score (p = 0.007). Gender, was a significant variable for E.E. (Mann-Whitney test; p=0,046). Educational level correlated with all MBI dimensions. Mean E.E. score and mean DP score (p<0.001) were higher in those who had master and / or Phd (p=0.039). However mean PA score (p=0,043) found to be lower. The number of years working as a physiotherapist correlated with the level of PA (p = 0,038). Multiple regression analysis revealed that the predictors of 1) E.E. was the gender (p=0,037) 2) PA was the age group (p=0,003).conclusion: Burn out is a common problem in Greek physical therapists. Further research is needed in order to take the appropriate measures not only to identify this phenomenon, but also to prevent and confront it effectively. Key Words: Burn out, Physical Therapists, Health Professionals, Psychology ΕΙΣΑΓΩΓΗ Greece is a member of the European Union with a specific health system. The provision of health services is channeled through public and private carriers. All Greek citizens have access to free medical and pharmaceutical care, either/or part of it is covered by the state and the rest is given privately. Every business is obliged to cover the medical treatment of its employees, while the Greek citizen at the same time enjoys the right to a private insurance as well. 78 Cor. Author: M.Gouva,, T.E.I of Epirus, 4 th The etymology of the burnout syndrome in English language is defined as followed: weary myself gradually from within to the point of charring. It is a psychosocial syndrome, which occurs between individuals working in a vast working environment, especially in developed societies. It is a global and timeless phenomenon, an allegory, often used to describe a situation or a procedure similar to the putting out of a candle (Schaufeli & Bunnk, 2003). Klm National Highway Str. Ioannina - Athens 45500, Greece.
3 The word burnout gained its syndrome definition of professional exhaustion, ever since in 1974 the psychiatrist Freudenberger, who is considered father of this term, used it to define the saturation or exhaustion caused by the profession. According to Freudenberger, professional exhaustion is underlined, both from physical symptoms and behavioral indications. Among the somatic/physical symptoms are feeling of exhaustion, lack of sleep, breathing disorders, gastrointestinal problems and a vulnerability to common colds. Regarding behavior, the individual is found to be irritant, quick- tempered, easy to cry and unable to control his/her feelings, stubborn and not particularly flexible, cynical and introvert, blocking progress and changes. Symptoms of depression and paranoia have been observed, too (Freudenberg, 1974). Based on the worldwide research burn out occurs to medical and nursing staff. The excessive workload, the tight schedule, the lack of autonomy on taking decisions (Turnipseed, 2006), but also the acute and chronic work demands (Lederer et al., 2008) result the development of burn out. Professionals experiencing burn out, have physical, mental changes or changes in behavior (Theofilou, 2009). In Greece, research that refers to nursing staff, shows an outdated and unrealistic public image of the profession, its poor work conditions (Dimitriadou et al., 2009, Markaki, et al., 2006), but also the disappointment of the work enviroment (Kapela, et al., 2002, Kotrotsiou,1998). The physiotherapist is in danger, on the same level with other health professionals, to develop the syndrome of professional rehabilitation, since his job demands a close connection with the patient for an extended period of time. In particular, the physiotherapist, who works in a rehabilitation center, is involved in domains concerning the quality of life and family relations. Findings from the overview of international literature are very few, compared to other specialties. A recursion to past similar studies, starting from the 1984 research of Schuster et al to professional physiotherapists showed high burnout levels, followed by a more recent research in 2002 in Japan showing medium burnout levels and finally in the 2010 study (Pavlakis et al., 2010) whose results exhibited high depersonalization and emotional exhaustion levels to physiotherapists who consider their job quite stressful. Taking into account all of the above, but acknowledging also that the data regarding physiotherapists in Greek society is few, a study whose aim was the research of this phenomenon in this particular population was set. PURPOSE The aim of this study was the research of professional exhaustion of Greek physiotherapists working in public and private hospitals and rehabilitation centers. Research questions 1. If male physiotherapists are different from female physiotherapists regarding/ to the variables considered. 2. If the younger in age are different from the older regarding the variables considered. 3. If the professionals with a higher educational level differ from the ones with a lower educational level regarding the variables considered. 4. If the years of experience are related to the appearance of the phenomenon. METHOD Individuals, who accepted to participate in this study, had to abide by the following criteria/conditions: 1) adequate knowledge, both oral and written, of the Greek language 2) graduates, having a license to practice and currently working in private and public hospitals and rehabilitation centers. The decision for the qualification of the participants was taken by the scientific officer of the current study in cooperation with the researcher. The researcher, after appointment, notified the physiotherapists working in public and private hospitals and rehabilitation centers and proceeded to the description of the nature and aim of the study clarifying/exemplifying the ability/potentiality to accept or refuse their participation or even withdraw during the conduct of the study. Beyond these, another aim of this communication, which had an average duration of 15 minutes, was the creation of a safe context and a feeling of confidence. Finally, the numbers of the physiotherapists who qualified, accepted to participate and successfully completed the questionnaires were 176. The Maslach & Jackson Burnout Inventory (MBI), includes 22 proposals and measures/counts the three dimensions of professional exhaustion, as mentioned in the three dimension model of Maslach Emotional Exhaustion, Depersonalization, Lack of Personal Fulfillment- Personal Achievements. This is (about) the most widely used tool internationally for the measurement of professional exhaustion. This catalogue is considered to be reliable, valid and easy to use. This instrument has been validated in the Greek language by Anagnostopoulos et al. and has been recently tested on a sample of oncology nurses and physicians. High scores in the EE or DP scales or low scores in the personal accomplishment scale indicate high levels of burnout. The questionnaire is divided in two parts-the first part includes a self-report questionnaire which examines 4 sectors in the context of 11 subjects: a) indicators of demographic situation ( e.g. gender, age, marital status ), b) indicators of professional status and scientific training ( e.g. academic qualifications, job position ), c) factors contributing to professional development. In the two first sectors, the participants were asked to fill accurately the requested data (academic titles, job position etc). The second part includes the M.B.I. questionnaire. ETHICAL ISSUES The current research study responds to the fundamental ethical principles, which govern the conduct of psychological research. The responsible for the M.A. program approved the conduct of the current study. Before the collection of the data, there was a briefing between the chief of the department of physical and medical rehabilitation and the researcher, regarding his consent for the conduct of the study. The chief of the department also took over informing the 79
4 N % Age, mean score± SD 35,2±9,3 Gender Educational level Postgraduate training Men 76 43,2 Women ,8 T.E.I ,0 Master 40 85,1 Phd 3 6,4 Master and Phd 4 8,5 Single ,2 Marital status Married 67 38,1 Divorced 3 1,7 Table 1 Social-demographic characteristics of the sample Lowest price Highest price/peak Mean SD Median Emotional exhaustion 0,0 48,0 20,9 8,8 20 (15-26) Personal achievements 13,0 48,0 37,4 6,5 38 (34-42) Depersonalization 0,0 26,0 6,7 5,1 Table 2. The ratings in the dimensions of burn out 6 (3-10) physiotherapists about the current research study, as well as getting them in contact with the researcher. DATA ANALYSIS The statistic program SPSS 17.0 was used for the analysis. The average prices (mean), the standard deviations (SD), the medians and the interquartile ranges were used for the description of the quantitative variables. For the comparison of the quantitative variables between two teams the Mann- Whitney test was used whereas for the comparison of the quantitative between two or more different groups the Kruskal-Wallis criterion was used. For the checking of a type I error, due to the multiple comparisons, the correction Bonferroni was used, whereby the significancy level is 0,05 κ ( κ= number of comparisons). For the checking of the relation between two quantitative variables the Spearman (r) correlation coefficient was used. The correlation is considered low when the correlation coefficient ranges between 0, 31 to 0,5 and high when it is above 0,5. The linear regression analysis with the procedure of consecutive inclusion/deduction (stepwise) was used for the discovery of independent factors related to the dimensions of various scales from which rate dependences and standard errors occurred. The linear regression analysis was conducted with the usage of ranks due to the asymmetric distributions of the scale. The significance levels were bilateral and the statistic significancy was 0, RESULTS The sample is consisted of 176 people with an average age of 35,2 (+9,3). On table 1 are given the demographics of the participants. 56,8 of the participants were women. All were Technological Institutions graduates. Τhe 93,6% of the people who had some post gradual training had masters. Finally, the 60,2% were single. Τhe 36,9% of the participants had been working in the field of physiotherapy for 5 years at the most, while 5,7% had years. 28,45% of the participants was up to 29 years old, 42,6% between and 29% was 38 and above. Half of them were public servants and the other half private ones. Factors contributing to the professional development of the participants in their workspace The participants were asked to say their opinion on which factors they consider that contribute to their professional development in their workspace. The most influential factor to their professional development was the educational level with a 65,1 percentage followed by the personality factor with a 62,9 percentage. BURNOUT CHARASTERISTICS IN GREEK PHYSIOTHERAPISTS Table 2 shows the ratings in the dimensions of burn out of the participants. Higher scores indicate bigger burn out. The majority of the participants had low emotional exhaustion reaching a 52,0% percentage. Also, 45,3% of them had medium personal achievements and 49,1% low depersonalization.
5 Age Gender Master / Phd Marital status Professional sector Number of years working in the field of physical therapy Emotional exhaustion Personal achievement Depersonalization Mean score ±SD Median εύρος) (Ενδ. P Mann- Whitney Mean score ±SD Median εύρος) (Ενδ. P Mann- Whitney Mean score ±SD (Ενδ. εύρος) <29 22,3±9,3 21,5 (14-28) 0,463 35,6±6,5 37 (32-40) 0,007 7,4±5,5 6 (3-11) 0, ,9±7,8 20 (16-25) 37,3±5,7 38 (35-42) 6,6±4,7 5,5 (3-10) >38 19,6±9,8 18 (14-26) 39,5±7 40 (36-46) 6,1±5,2 5 (2-10) Men 19,3±7,9 18 (14-25) 0,046 38,4±6,3 39 (36-42,5) 0,052 7,2±5 7 (3-10) 0,145 Women 22,2±9,3 22 (16-28) 36,6±6,5 37 (33-41) 6,3±5,1 5 (2-9) P Mann- Whitney Όχι 20,1±8,9 19 (14-25) 0,039 38±6,6 38 (35-42) 0,043 5,9±4,9 5 (2-8,5) <0,001 Ναι 23,1±8,3 22 (16-28) 35,8±5,9 37 (31-41) 8,7±4,9 8 (5-12) Single 20,8±8,5 19 (14-27) 0,744 37,1±5,4 38 (34-41) 0,146 6,9±5,1 6 (3-10,5) 0,409 Married / divorced 21,1±9,4 21 (15-26) 37,9±7,9 38 (35-43) 6,3±5 5 (2-9) Public 19,8±8,9 19 (13-25) 0,120 38,3±6,8 39 (35-43) 0,053 7±5,6 6 (2-11) 0,780 Private 22±8,7 21 (16-27) 36,6±6,1 37 (33-40) 6,4±4,5 5 (3-9) ,4±9,2 20 (14-27) 0,270* 36±6,2 37 (33-40) 0,038* 7,2±5,6 6 (3-11) 0,712* ,2±8,3 18,5 (14-23) 37,8±5,9 38 (34-42) 6,2±4,6 5 (2-10) More than 10 21,7±8,8 21 (16-27) 38,6±7 39 (36-43) 6,5±4,8 6 (2,5-9,5) Table 3. social and demographic characteristics Table 3 presents the MBI subscale scores by social and demographic characteristics. Age group correlated with PA mean score (p = 0.007). People under the age of 29 had significant, lower personal achievements than people over the age of 38. Mean E.E score 22,2±9,3 was higher in woman than in men (p =0,046). Gender, however, was not a significant variable for DP and PA. Marital status and employment sector did not correlate with MBI dimensions. However, postgraduate level correlated with all MBI dimensions. Mean E.E. score and mean DP score (p<0.001) were higher in those who had master and / or Phd (p=0.039). However mean PA score (p=0,043) was lower in those who had master and / or Phd (p=0.039). The Kruskal-Wallis test revealed that the number of years working as a physiotherapist correlated with the level of PA (p = 0,038) showing that people with less experience had lower feelings of PA. FACTORS ASSOCIATED WITH HIGH SCORES OF BURNOUT Multiple regression analysis revealed that the predictors of 1) E.E. was the gender (p=0,037) 2) PA was the age group. Table 4 shows the above results. DISCUSSION Our research has explored the appearance of burnout in Greek physical therapists and its relationship with the social and demographic characteristics. To our knowledge, this is the first published nationwide research in the field in Greece. One first conclusion from this study is that it s findings have many similarities with previous studies (Pavlakis et al., 2010; Calzi et al., 2006) showing that the physiotherapist is in danger, on the same level with other health professionals, to develop the burnout syndrome, since his job requires a close relationship with the patient, for a long period of time, while in parallel he or she engages in areas regarding the quality of life and family affairs. The percentage of physiotherapists with high EE was lower in this research compared to the findings of other studies (Ogiwara et al., 2002; Donohoe et al., 1993). This finding is different than that reported by Pavlakis et al, (2010) who reported higher personal achievements, and it is proposed that the interrelation of medium personal achievements and relatively high emotional exhaustion be investigated in future research since it may indicate that Greek physiotherapists may not be as efficient in handling aspects of professional stress. An element rarely considered in research studies is that, participants with post-graduate and/or doctoral studies experienced significantly higher emotional exhaustion, higher depersonalization and lower personal achievements, compared to the ones holding either a masters or a PhD. According to Maslach et al., (2001) this is attributed, either to the fact that they have increased tasks, or to that the higher expectations of people over qualified and scientifically sufficient do not respond to reality. Gender does not constitute a strong dispositional factor, but as expected, according to the international literature (Pavlakis et al, 2010; Maslach et al, 2001) women had a significally higher emotional exhaustion compared to men. The difficulties for women were more, mainly due to the multiple roles of mother, wife, family and home care taker, and also that of professional (Yang, et al., 1997). 81
6 Β SE P Gender Men 0,00* 13,13 6,26 0,037 Women Age <29 0,00* Table 4. Multiple Regression Analysis ,73 8,13 0,189 >38 27,82 9,10 0,003 As it was expected, people under 29 years old had significantly lower personal achievements compared to people over 38, but also the participants with 5 years the most in the field of physical therapy, had considerably lower personal achievements compared to the ones that had been in the business for more than 10 years. According to literature, age is related to professional experience, so that is why younger professionals are more apt, to experience burn out. The existence of high and unrealistic expectations results, from the young of their age and the lack of sufficient clinical experience (Ogiwara et al., 2002). The physiotherapist who because of sufficient clinical experience realizes that a patient will not have the expected rehabilitation, confines to the use of specific techniques and rehabilitation methods, something which protects both him and the patient (Calzi et al., 2006). CONCLUSIONS Burn out is a common problem in Greek physical therapists. In all, 14,5%, 22,8 and 28,8 scored high levels of EE, DP, PA. High scores of burn out are related to several variables, such as: the gender, the age, years of experience and the postgraduate level. Further research is needed in order to take the appropriate measures not only to identify this phenomenon, but also to prevent and confront it effectively. REFERENCES 1. Calzi, Ci Li, Parinelli, M., Ergoland, M., Alianti, M., Manigrasso, V., Taronni, A.M. (2006). Physical rehabilitation and burnout different aspects of the syndrome and comparison between healthcare professionals involved. Europa Medicophysical, 42(1), Dimitriadou-Panteka, A., Lavdaniti, M., Minasidou, E., Tsaloglidou, A., Kafkia, Th., Sapountzi-Krepia, D. (2009). Working conditions of nursing personnel and their effects in patients and personnel. Rostrum of Asclepius, 8 (3), Donahoe, E., Nawawl, A., Wllker, L., Schlndler, T., Jette, U. (1993). Factors associated with burnout of physiotherapists in Massachusetts rehabilitation hospitals. Physical Therapy, 73(11), Freudenberger, H.J. (1974). Staff Burnout. Journal of Social Issues, 30(1), Kapela M., Minetou M. & Ziga S. (2002). Measuring nurses' satisfaction with their work. Nosileftiki, 2, Lederer, B., Kinzl, J. F., Traveger, C., Dosch, J., Summan, G. (2008). Fully developed burnout and burnrout risk in intensive care personnel in a university hospital. Anaesthesia Intencive Care, 36(2), Markaki, A., Antonakis, N., Philalithis, A. & Lionis, C. (2006). Primary health care nursing staff in Crete: an emerging profile. International Nursing Review, 53, Maslach, C., Scaufeli, W.B., Leiter, M.P. (2001). Job Burnout. Annual Review Psychology, 52, Ogiwara, S., Hayashi, H. (2002). Burnout amongst Physiotherapists in Ishikawa Prefecture. Journal Physical Therapy Sci, 14 (1), Papadatou, D., Anagnostopoulos, F., Monos, D. (2002). Factors contributing to the development of burnout in oncology nursing. Br. J. Med. Phycol, 67 (2) Pavlakis, A., Raftopoulos, V., Theodorou, M. (2010). Burnout syndrome in Cypriot physiotherapists: a national survey. BMC Health Serv Res, 10 (63). 12. Schaufeli, W.B &. Bakker, A.B. (2004). Job demands, job resources, and theirrelationship with burnout and engagement: a multi-sample study. Journal of Organizational Behavior, 25 (3), Schuster, N., Nelson, D., Quisling, C. (1984). Burnout among physical therapists. Physical Therapy. 64(3), Theofilou, P. (2009). Burn-Out Syndrome in the Field of Health, e-journal of Science & Technology (e-jst), 4, Turnispeed, D.L. (1994). An Analysis of the Influence of Work EnvironmentVariables and Moderators on the Burnout Syndrome. Journal of Applied Social Psychology. 24 (9), Yang, N., Chen, C.C., Hunt, R.G. (1997). Sources of work-family conflict and life stress: A Sino-U.S. Comparison of the effects of work and family demands. Academy of Management Best Paper Proceedings, Κotrotsiou Ε. (1998). The professional profile of the modern Greek nurses. Proceedings of the 25th National Nursing Conference, Heraklion, Crete. 82