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Relationship of Burnout With Personality, Alexithymia, and Coping Behaviors Among Physicians in a Semiurban and Rural Area in Turkey a
b
Okan Taycan MD , Serap Erdoğan Taycan MD & Cihat Çelik MA
c
a
Adult Psychiatry Unit, Tokat State Hospital , Tokat , Turkey
b
Department of Psychiatry , Faculty of Medicine, Gaziosmanpasa University , Tokat , Turkey
c
Department of Psychology , Faculty of Arts and Sciences, Mus Alparslan University , Mus , Turkey Accepted author version posted online: 08 Mar 2013.Published online: 10 Dec 2013.
To cite this article: Okan Taycan MD , Serap Erdoğan Taycan MD & Cihat Çelik MA (2014) Relationship of Burnout With Personality, Alexithymia, and Coping Behaviors Among Physicians in a Semiurban and Rural Area in Turkey, Archives of Environmental & Occupational Health, 69:3, 159-166, DOI: 10.1080/19338244.2013.763758 To link to this article: http://dx.doi.org/10.1080/19338244.2013.763758
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Relationship of Burnout With Personality, Alexithymia, and Coping Behaviors Among Physicians in a Semiurban and Rural Area in Turkey Okan Taycan, MD; Serap Erdo˘ gan Taycan, MD; Cihat C ¸ elik, MA
ABSTRACT. This present study aimed to assess levels of burnout, to investigate the extent to which personal characteristics and coping behaviors are related to burnout, and to establish the predictors of burnout among physicians in a semiurban and rural area. A sample of 139 physicians was assessed using the Maslach Burnout Inventory, Eysenck Personality Questionnaire, Toronto Alexithymia Scale, and Ways of Coping Inventory. The level of burnout was found to be moderately higher than those reported among urban physicians. A forward stepwise multiple regression analysis indicated that neuroticism, occupation (specialist vs general practitioner), helpless, self-confident, and social support seeking approaches were predictors of burnout. The results showed that burnout was negatively related with problem-focused copping strategies, and positively with emotion-focused coping strategies. Fostering problem-focused coping strategies in physicians might be useful in the reduction of burnout. KEYWORDS: alexithymia, burnout, coping behavior, personality, physicians
B
urnout was first introduced by Freudenberger in 1974.1 The definition of burnout as we know today was formulated by Maslach and Jackson in 1982 as a prolonged response to chronic emotional and interpersonal stressors in the professions where individuals work mainly with humans such as physicians, mental health professionals, nurses, and teachers. It is a multidimensional concept consisting of emotional exhaustion, depersonalization, and personal accomplishment.2 Emotional exhaustion is the central quality of burnout and refers to feelings of being emotionally overextended and a notable reduction in one’s available emotional resources. Depersonalization is defined as behaving towards the caretakers without any emotion, as if they are not unique individuals. Personal accomplishment refers
to feelings of competence and successful achievement related to one’s work.3 Practicing as a physician requires intensive involvement with people; thus, physicians are considered to be vulnerable to experiencing burnout.4,5 Burnout in physicians is crucial not only because it potentially causes health problems such as fatigue, insomnia, and physical exhaustion but also because it influences patient satisfaction and treatment outcomes. Therefore, prevention of burnout in physicians is essential towards improving the quality of patient care.6,7 The issue of which factors influence the development of burnout is controversial among researchers. Whereas some researchers point to the importance of organizational factors such as stressful conditions at work, others refer to interpersonal variables such as problems concerning relationships
Okan Taycan is with the Adult Psychiatry Unit, Tokat State Hospital, Tokat, Turkey. Serap Erdo˘gan Taycan is with the Department of Psychiatry, Faculty of Medicine, Gaziosmanpasa University, Tokat, Turkey. Cihat C ¸ elik is with the Department of Psychology, Faculty of Arts and Sciences, Mus Alparslan University, Mus, Turkey. 2014, Vol. 69, No. 3
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with colleagues.6,8–11 According to these views, environmental factors pertaining to the workplace play a major role in the development of burnout. However, these factors could not adequately explain why under the same working conditions, one individual burns out, whereas another does not.12 Personality plays a significant role in how people perceive stress and may influence their way of coping, which in turn may influence the development of burnout.13 Piedmont indicated that even when situational variables were controlled, personality continued to account for a significant portion of the variance in burnout scores.14 Previous studies showed that some personality traits such as neuroticism, extraversion, or alexithymia may increase the sense of stress and contribute to the development of burnout.12,15–18 Fontana and Abouserie found that stress level was positively correlated with psychoticism and neuroticism but correlated negatively with extraversion. They found that extraversion and neuroticism were the best predictors of stress levels.19 Similarly, Schaufeli and Enzmann indicated that neuroticism was one of the strongest personality correlates of burnout.20 Alexithymia is characterized by impoverishment of fantasy, a poor capacity for symbolic thought, and difficulties in identifying and expressing feelings.21 It is, by definition, considered to be a stable personality trait.22 However, some authors claimed that alexithymia could be a temporary feature rather than a personality trait.23,24 In both cases, alexithymic individuals do not only have difficulties in identifying one’s own feelings but also have difficulties in identifying emotions of others, resulting in an inability to build intimate relationships. Deteriorated relations in the work climate may especially predispose individuals with alexithymia to stressrelated health problems, including burnout. Several studies have yielded the interrelationship between alexithymia and burnout.25,26 Burnout is also defined as an inability to cope with emotional stress at work. It is well documented that reactions to stress can vary among individuals depending on the coping strategies used.27 Accordingly, coping behaviors of individuals contribute to the explanation of why exposure to the same stressors may cause burnout in some subjects but not in others.16 Two types of coping were identified by Lazarus and Folkman: problem-focused coping, which attempts to manage or alter the problem causing distress; and emotionfocused coping, consisting of attempts to reduce the negative feelings associated with the threat rather than alter the source of the threat.28 Both types of coping are used in most situations.29,30 However, it was also claimed that the use of problem-focused coping strategies may prevent burnout, whereas emotion-focused strategies contribute to burnout.31 Several studies have shown the interrelationship between burnout and coping strategies with stress.15,16,18,31,32 Turkey has a highly complex, fairly organized and underfunded health care system, which imposes extra stress to work life of physicians and contributes to burnout.4 Research investigating burnout among physicians in this country has mostly taken place in urban areas.4,33–36 Little is known about 160
burnout and related factors among physicians working at semiurban and rural areas in Turkey. However, it has been reported that rural physicians are more prone to experiencing burnout because they face unique practice and personal stressors, many of which are beyond their control, such as excessive clinical workload, professional and social isolation, difficulty taking time off, and heavy on-call requirements.5 This present study aimed (a) to assess levels of burnout; (b) to investigate the extent to which personal characteristics and coping behaviors are related to burnout; and (c) to establish the predictors of burnout among physicians working in a semiurban and rural area. To our knowledge of the literature, a study focusing on burnout and relationships with personality and coping behaviors among semiurban and rural physicians has not been done before. We expected to find (a) high levels of burnout in semiurban and rural physicians; (b) a positive relationship between neuroticism, alexithymia, and burnout; and (c) that physicians who experience less burnout would more likely use problem-focused strategies to cope with stress. METHODS Sample selection and procedures The survey was conducted on all physicians working in the province of Mus located in the eastern Turkey. Mus has a population density of 56 people per square kilometer, whereas the population density of Turkey is 88 people per square kilometer. It is one of the least developed provinces in Turkey. According to a report indicating socioeconomic development ranking of provinces in Turkey published by the State Planning Organization, Mus was indicated to be the poorest and the least developed province of 81 provinces in the country.37 Although there are some population centers of more than 10,000 people in the province, taken both the demographic properties and socioeconomic conditions of the region into consideration, Mus is considered to be a combination of mostly rural and partly semiurban areas. The study was approved by the institutional review board of Inonu University, Malatya, and the Mus Provincial Directorate of Health. Physicians who were eligible for the study were individually invited to participate in the study after the nature of the study and methods for ensuring confidentially were explained by the researcher. Physicians were requested to complete the forms and return them either in person or by mail. All participants provided written informed consent. There were 207 physicians working in the province in August 2008 (97 specialists, 110 general practitioners). Because the study concerned actual work conditions during clinical practice, we excluded 12 physicians who worked exclusively as administrators—they were either provincial health directors (n = 2, 0.9%) or head physicians of hospitals (n = 10, 4.8%). Of the 195 physicians who were eligible for the study, 12 did not wish to participate or did not return the questionnaires (6.1%) and 44 (22.5%) could not be reached because Archives of Environmental & Occupational Health
they were either on vacation or sick leave when the study was conducted. Consequently, the response rate was 71.2%; the final sample of the study consisted of 139 physicians. This present study is a part of a larger study on mental health of semiurban and rural physicians. Measures Participants provided sociodemographic data and completed a series of self-report questionnaires, including the Maslach Burnout Inventory, the Eysenck Personality Questionnaire Revised—Abbreviated Form, the Toronto Alexithymia Scale-20, and the Ways of Coping Inventory.
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Sociodemographic Data Form This form was developed by researchers to obtain data related to demographic and organizational characteristics of the physician sample, including age, gender, marital status, occupation, years in practice, satisfaction with salary, and daily number of patients. Maslach Burnout Inventory (MBI) The MBI—Human Services Survey was used to measure frequency of burnout. The scale consists of 22 items constituting 3 subscales: emotional exhaustion, depersonalization, and personal accomplishment. The higher the emotional exhaustion and depersonalization score and lower the personal accomplishment score, the more a physician would be suffering from burnout.2 The Turkish translation of MBI has been shifted to 5-point Likert style from the original 7-point Likert style, since it was concluded that the former was more appropriate for Turkish culture. Each subscale score can be categorized as low, moderate, or high burnout as defined by normative data for the 7-point scale version. However, normative data for these categories were unavailable for the 5-point Likert style Turkish version. Therefore, only mean scores of each subscale were used in this study. The Turkish translation of the MBI has been shown to be valid and reliable in Turkish participants. Cronbach’s alpha scores were .83 for emotional exhaustion, .65 for depersonalization, and .72 for personal accomplishment.38 Eysenck Personality Questionnaire Revised—Abbreviated Form (EPQR-A) Personality traits were measured using one of a series of personality inventories developed by Eysenck and Eysenck.39 The EPQR-A has 24 items, 6 for each of the traits of neuroticism, extraversion, and psychoticism, and 6 for the lie scale.40 Extraversion represents sociability, liveliness, and impulsivity; neuroticism represents emotional instability and anxiousness; psychoticism represents tough-mindedness, aggressiveness, coldness, and egocentricity; and the lie scale represents unsophisticated dissimulation and social naivety or conformity.39 The psychoticism subscale was found to be correlated with a variety of traits such as impulsiveness, 2014, Vol. 69, No. 3
lack of cooperation, oral pessimism, rigidity, low superego controls, low social sensitivity, low persistence, lack of anxiety, and lack of feelings of inferiority. Howarth criticized the lack of clarity related to this concept, as psychoticism was the least univocal compared with neuroticisim and extraversion.41 This issue raises the question of what psychoticism really measures. In order to clearly focus on personality traits that are well-defined and have been extensively studied, only neuroticism and extraversion subscales were selected to be used in our survey. The Turkish version of the EPQR-A was modified by Karancı et al.42 Cronbach’s alpha scores for extraversion, neuroticism, psychoticism, and lie scales were .78, .65, .42, and .64, respectively. Toronto Alexithymia Scale-20 (TAS-20) Alexithymia was assessed with the 20-item TAS, which consists of 3 subscales: difficulty in identifying feelings, difficulty in describing feelings, and externally oriented thinking.43 The Turkish translation of the scale revealed good internal reliability (Cronbach’s alpha = .76) but did not support the original TAS-20 3-factor structure.44 Therefore, only the total score was used in this study. Ways of Coping Inventory (WCI) The WCI was developed by Lazarus and Folkman in 1980 and has 30 items pertaining to 5 coping behaviors or approaches: self-confidence, optimistism, social support seeking, helplessness, and yielding.29 Each subscale is scored separately. A higher score indicates that the coping strategy is more often used. Self-confident, optimistic, and social support seeking approaches are evaluated as effective ways of coping with stress, representing problem-focused coping strategies; the other 2 approaches (helpless and yielding approaches) are evaluated as ineffective/emotional directed ways of coping with stress, representing emotion-focused coping strategies. A Turkish version of the WCI was found to have satisfactory reliability and validity characteristics.45 Cronbach’s alphas of subscales were .69 for self-confident approach, .63 for optimistic approach, .72 for social support seeking approach, .67 for helpless approach, and .68 for yielding approach.45 Statistical analysis All discrete (or continuous) variables were found to be normally distributed based on the Kolmogorov-Smirnov test. The chi-square for categorical variables and independent t tests for continuous measures were used to test the statistical significance of differences between general practitioners and specialists on demographic and organizational characteristics. Bivariate relationships between continuous variables were examined with Pearson product moment correlations. The independent associations between each burnout dimension (emotional exhaustion, depersonalization, personal accomplishment) and personality traits 161
(extraversion, neuroticism, alexithymia) and coping behaviors (self-confident, optimistic, social support seeking, helpless, and yielding approaches) were assessed using forward stepwise multiple regression, controlling for age, gender, and occupation. The variables that were added to the regression were chosen automatically by SPSS (SPSS, Chicago, IL, USA). Variance inflation factors were calculated to check for multicollinearity among the predictors in the regression analyses. All analyses were conducted with SPSS version 11.5, and all statistical tests were 2-sided with a p < .05 significance level.
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RESULTS Seventy-six (54.7%) of 139 participants in the study were general practitioners. The mean age of the sample was 31.05 ± 4.84 years. Of the subjects, 93 (66.9%) were male and 72 (51.8%) were married. The mean years in practice were 6.07 ± 4.71. Table 1 shows the comparison of demographic and organizational characteristics in specialists and general practitioners. Accordingly, specialists and general practitioners differed significantly in terms of age, marital status, years in practice, daily number of patients, and salary satisfaction. Specialists were more likely older, married, satisfied with their salary, and to have a greater daily number of patients than general practitioners. It was concluded that the significant difference in years of practice between specialists and general practitioners was related to the age difference. The difference in gender was not statistically significant.
The mean score of emotional exhaustion for the whole sample was 14.91 ± 7.02, depersonalization was 5.80 ± 3.33 and personal accomplishment was 20.35 ± 3.85. Table 2 shows the correlations of burnout dimensions with demographic and organizational characteristics of the sample. Depersonalization scores of specialists were significantly higher than those of general practitioners. Physicians who have more than 50 patients daily had significantly higher scores on depersonalization and lower scores on personal accomplishment. No statistically significant difference was found between MBI subscale scores of physicians obtained according to their age, marital status, years of practice, and level of satisfaction with the salary. The bivariate correlations of burnout dimensions with personality traits, alexithymia, and coping behaviors are shown in Table 3. Of the personality variables, neuroticism was positively correlated with emotional exhaustion and depersonalization, and negatively correlated with personal accomplishment. Extraversion was negatively correlated with emotional exhaustion and depersonalization, and positively associated with personal accomplishment. Alexithymia was significantly and positively correlated with emotional exhaustion and depersonalization. No statistically significant relation was found between alexithymia and personal accomplishment. In terms of coping behaviors, emotional exhaustion and depersonalization were negatively correlated with problem-focused coping strategies, including self-confident and optimistic approaches; positively correlated with emotion-focused coping strategies, including helpless approach. Personal accomplishment was positively correlated with problem-focused coping strategies
Table 1.—-Comparison of Demographic and Organizational Characteristics in Specialists and General Practitioners
Characteristic Gender (male) n % Age (years) Mean SD Marital status (married) n % Years in practice Mean SD Daily number of patients (≥50 patients) n % Satisfaction with the salary (unsatisfied) n % ∗p
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Specialists (n = 63)
General practitioners (n = 76)
42 66.6%
51 67.2%
33.96 3.60
28.63 4.40
43 68.2%
29 38.1%
9.80 3.00
2.98 3.47
45 71.4%
40 52.6%
37 58.7%
60 78.4%
Statistical analysis χ 2 = 0.00 t = −7.71∗∗∗ χ 2 = 12.49∗∗∗ t = −12.23∗∗∗ χ 2 = 5.12∗ χ 2 = 6.67∗
< .05; ∗∗∗ p < .001.
Archives of Environmental & Occupational Health
Table 2.—-Correlations of Burnout Dimensions With Demographic and Organizational Characteristics of the Sample Characteristic
Emotional exhaustion
Depersonalization
Personal accomplishment
Gender Age Marital status Occupation General practitioner Specialist
t = 0.76 r = .06 t = 1.04 t = −1.92
t = −0.76 r = .11 t = 0.20
t = 1.73 r = .01 t = 0.02 t = 0.45
Years in practice Daily number of patients ≤50 patients >50 patients
r = .07 t = −1.88
Satisfaction with the salary
t = 1.40
M = 5.02, SD = 3.28 M = 6.74, SD = 3.16 t = −3.12∗∗ r = .16 M = 4.92, SD = 2.94 M = 6.36, SD = 3.45 t = −2.53∗ t = 0.43
r = .00 M = 21.16, SD = 3.61 M = 19.83, SD = 3.92 t = 2.00∗ t = −0.00
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Note. r = bivariate Pearson correlation. ∗ p < .05; ∗∗ p < .01.
(self-confident, social support seeking, and optimistic approaches) and negatively correlated with emotion-focused coping strategies (helpless, and yielding approaches). The most frequently used coping strategy was reported to be selfconfident approach (2.07 ± 0.45) and the least frequently used was the yielding approach (0.88 ± 0.44). Table 4 shows the stepwise multiple regression model of concurrent independent correlates of burnout dimensions. Each burnout dimension (emotional exhaustion, depersonalization, personal accomplishment) was regressed on demographic characteristics (age, gender, occupation), personality traits (extraversion, neuroticism, alexithymia), and coping behaviors (self-confident, social support seeking, optimistic, helpless, and yielding approaches). Emotional exhaustion was predicted by neuroticism, occupation (being a special-
ist), and helpless approach, which all together accounted for 26% of the variance. Depersonalization was predicted by neuroticism, occupation (being a specialist), and selfconfident approach, which all together accounted for 23% of the variance. Self-confident approach and social support seeking approach were predictors of personal accomplishment, which explained 23% of the variance. COMMENT The MBI scores of our study were consistent with those obtained from the largest study on burnout among 1750 urban, semiurban, and rural physicians in Turkey, as the emotional exhaustion, depersonalization, and personal accomplishment mean scores were 15.48, 5.51, and 22.06, respectively (MBI
Table 3.—-Bivariate Correlations of Burnout Dimensions With Personality Traits, Alexithymia, and Coping Behaviors Variable Burnout Emotional Exhaustion Depersonalization Personal Accomplishment Personality traits Extraversion Neuroticism Alexithymia Coping behaviors Self-confident approach Social support seeking approach Optimistic approach Helpless approach Yielding approach ∗p
Emotional exhaustion
Depersonalization
Personal accomplishment
— .64∗∗∗ −.28∗∗∗
.64∗∗∗ — −.38∗∗∗
−.28∗∗∗ −.38∗∗∗ —
−.20∗ .43∗∗∗ .26∗∗∗
−.25∗∗ .35∗∗∗ .29∗∗∗
.27∗∗∗ −.28∗∗∗ −.06
−.32∗∗∗ −.04 −.35∗∗∗ .34∗∗∗ .12
−.31∗∗∗ −.12 −.33∗∗∗ .25∗∗ .08
.45∗∗∗ .21∗ .33∗∗∗ −.20∗ −.20∗
< .05; ∗∗ p < .01; ∗∗∗ p < .001.
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163
Table 4.—-Forward Stepwise Multiple Regression Model of Concurrent Independent Correlates of Burnout Dimensions‡ Dependent variable Emotional exhaustion
Depersonalization
Personal accomplishment
Independent variable
R2
Standardized beta (β)
t
Neuroticism Occupation (0 = general practitioners; 1 = specialists) Helpless approach Neuroticism Occupation (0 = general practitioners; 1 = specialists) Self-confident approach Self-confident approach Social support seeking approach
.19 .22 .26 .12 .20 .23 .20 .23
.36 .19 .19 .30 .26 −.18 .44 .18
4.51∗∗∗ 2.56∗ 2.42∗ 3.76∗∗∗ 3.52∗∗ −2.32∗ 5.89∗∗∗ 2.49∗
‡Variables in the model: demographic factors (age, gender, occupation) personality traits (extraversion, neuroticism, alexithymia), and coping behaviors
(self-confident, optimistic, social support seeking, helpless, and yielding approaches). < .05; ∗∗ p < .01; ∗∗∗ p < .001.
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∗p
scores of urban, semiurban, and rural physicians were not analyzed separately).46 Since the Turkish translation of MBI has 5-point Likert style instead of 7-point Likert style in the original scale, it did not allow us to compare the rough results obtained from MBI with those from the international literature. A number of studies from Turkey have reported higher burnout scores in psychiatrists, and in physicians working in university hospitals than those obtained in our study.35,47 Such higher scores could be the result of differences in the physician samples. Indeed, it has been indicated that psychiatrists are vulnerable to experiencing burnout, more so than other physicians.48 Two other studies of 598 and 384 urban physicians consisting of both specialists and general practitioners reported lower burnout scores, indicating that semiurban and rural physicians in our sample were more susceptible to experiencing burnout than their urban counterparts.4,33 Alexithymia showed a positive correlation with both emotional exhaustion and depersonalization, suggesting that physicians who have difficulties in verbalizing their feelings were more susceptible to burnout. Several previous studies supported this correlation.25,26,49 It was hypothesized that alexithymia is a predisposing factor to burnout due to inadequate coping with occupational stress.49 Indeed, the significant correlation between alexithymia and both emotional exhaustion and depersonalization disappeared after controlling for other variables, including coping strategies, with stress in our regression analysis. This finding may support that dysfunctional coping strategies mediated the effect of alexithymia on burnout. However, the cross-sectional design of our study does not allow us to infer causality. This direction of effect needs to be clarified with further studies that use a prospective design. The results of 3 separate stepwise multiple regression analyses that were conducted regressing each burnout dimension on physicians’ demographics, personality characteristics, and coping behaviors showed that age, gender, alexithymia, and among the coping strategies optimistic and 164
yielding approaches revealed no statistically significant contribution to any of 3 burnout dimensions. The regression models predicting emotional exhaustion and depersonalization showed similar patterns. Neuroticism was identified as the best predictor of both emotional exhaustion and depersonalization, which explained 19% and 12% of the variance, respectively. Neuroticism refers to the general emotional instability of the participants, and identifies individuals prone to psychological distress and maladaptive coping responses. It was hypothesized that both emotional exhaustion and depersonalization scales should have a high association with neuroticism.14 In this respect, our result is consistent with a number of studies that concluded that neuroticism was robustly associated with both emotional exhaustion and depersonalization.12,14,15,18,19 Occupation (specialist vs general practitioner) was also an independent predictor of both emotional exhaustion and depersonalization. It was found that specialists had a significantly greater daily number of patients than general practitioners in our study. This finding may potentially contribute to higher levels of burnout among specialists. Besides, semiurban and rural specialists in our sample seem more likely to deal with high work demands without adequate resources, feelings of isolation, and a lack of feedback. Exposure to such occupational stressors could be responsible for having higher levels of emotional exhaustion and depersonalization. Reporting a helpless approach (emotion-focused coping strategy) was another predictor of emotional exhaustion indicating that as physicians experienced higher emotional exhaustion, they relied more on emotion-focused coping strategies. It seems that emotion-focused coping strategies make physicians more prone to emotional exhaustion. There are several previous studies that are consistent with this finding.16,18,32 In a longitudinal study, Isaksson Ro et al indicated that reduction in emotion-focused coping and job stress preceded reduction in emotional exhaustion.50 Reporting a selfconfident approach (problem-focused coping strategy) was found to be a predictor of both depersonalization and personal Archives of Environmental & Occupational Health
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accomplishment. This seems to be a contradiction to our hypothesis at first glance, as problem-focused coping strategies were expected to play an important role in the prevention of burnout. However, the correlation between depersonalization and reporting a self-confident approach was negative, indicating that a higher depersonalization score was associated with less problem-focused coping strategy. These findings are in accord with a recent study in which a self-confident approach was found to be negatively correlated with depersonalization and positively correlated with personal accomplishment.16 The regression model predicting personal accomplishment showed a very different pattern. Neither demographic characteristics nor personality significantly predicted personal accomplishment. Problem-focused coping strategies (self-confident approach and social support seeking approach) were found to be significant predictors of personal accomplishment. This implies that physicians who had higher scores on personal accomplishment more likely use problem-focused coping strategies, which may help to prevent burnout. This finding is supported by a number of studies.26,31 Previous studies reported a negative correlation between stress and social support indicating that as stress levels rise, individuals rely more on social support in order to decrease their feelings of stress.30,51 Accordingly, our results showed that seeking social support as a coping strategy against stress may have contributed to an increase in feelings of achievement in physicians. However, it is not possible to draw any conclusions about the direction of causality from our findings. Further longitudinal studies are needed to clarify this issue. In terms of the limitations of our study, the first is the cross-sectional nature of the design, making it difficult to ascertain causality. Another limitation is the lack of an urban physician sample for comparison. Studies on burnout among urban physicians in Turkey lead us to suspect that urban physicians are not as burned out as their semiurban and rural colleagues.4,33 CONCLUSIONS In conclusion, our results supported that in addition to external factors such as occupational and organizational characteristics, internal factors such as personality traits and the way how physicians cope with stress play a significant role to experiencing burnout among semiurban and rural physicians. Particularly being a specialist, neuroticism and emotionfocused coping strategies may be predisposing factors to burnout. Our results showed that burnout was negatively related with problem-focused coping strategies, and positively related with emotion-focused coping strategies, suggesting that problem-focused copping strategies might be useful in preventing or at least reducing burnout. Furthermore, individuals with alexithymic features could be prone to experiencing burnout because of their inadequate capacity to cope with stress. In the light of these results, as personality is considered to be a rather stable construct, interventions focused 2014, Vol. 69, No. 3
on the improvement of stress coping strategies would be more helpful in the prevention of burnout in semiurban and rural physicians. Taken together, these findings contribute to the limited extant literature attempting to explain burnout among physicians in nonurban settings and highlight the importance of associations between burnout, personality, and coping behaviors. Future studies may evaluate self-care and problem-focused interventions intended to improve provider mental health and patient care in less urban settings. ********** The authors would like to express their gratitude to Tomas Jurkic (Concordia University, Montreal, Canada) for his constructive comments on earlier drafts of the paper. For comments and further information, address correspondence to Okan Taycan, MD, Kasikcibagları Mahallesi, Cihangir 2. Sokak, Tokkent Sitesi B Blok No: 5, Tokat, Turkey. E-mail: [email protected]
********** References 1. Fredeunberger HJ. Staff burn-out. J Soc Issues. 1974;30:159–165. 2. Maslach C, Jackson SE. Maslach Burnout Inventory, Manuel. Palo Alto, CA: Consulting Psychologists Pres; 1981 3. Maslach C, Schaufeli WB, Leiter MP. Job burnout. Ann Rev Psychol. 2001;52:397–422. 4. Ozyurt A, Hayran O, Sur H. Predictors of burnout and job satisfaction among Turkish physicians. Q J Med. 2006;99:161–169. 5. Thommasen HV, Lavanchy M, Connelly I, Berkowitz J, Grzybowski S. Mental health, job satisfaction, and intention to relocate. Opinions of physicians in rural British Columbia. Can Fam Physician. 2001;47:737–744. 6. Visser MRM, Smets EMA, Oort FJ, de Haes HCJM. Stres, satisfaction and burnout among Dutch medical specialists. CMAJ. 2003;168:271–275. 7. Gundersen L. Physician burnout. Ann Intern Med. 2001;135:145–148. 8. Taycan O, Kutlu L, Cimen S, Aydin N. [Relation between sociodemographic characteristics, depression, and burnout levels of nurses working in a university hospital]. Anadolu Psikiyatri Dergisi. 2006;7:100–108. [in Turkish] 9. Demir A, Ulusoy M, Ulusoy MF. Investigation of factors influencing burnout levels in the professional and private lives of nurses. Int J Nurs Stud. 2003;40:807–827. 10. Poncet MC, Toullic P, Papazian L, et al. Burnout syndrome in critical care nursing staff. Am J Respir Crit Care Med. 2007;175:698–704. 11. Embriaco N, Azoulay E, Barrau K et al. High level of burnout in intensivists: prevalence and associated factors. Am J Respir Crit Care Med. 2007;175:686–692. 12. Buhler KE, Land T. Burnout and personality in intensive care: an empirical study. Hosp Top. 2003;8:5–12. 13. DeLongis A, Holtzman S. Coping in context: the role of stress, social support, and personality in coping. J Pers. 2005;73:1633–1656. 14. Piedmont RL. A longitudinal analysis of burnout in the health care setting: the role of personal dispositions. J Pers Assess. 1993;61:457–473. 15. Shimizutani M, Odagiri Y, Ohya Y, et al. Relationship of nurse burnout with personality characteristics and coping behaviors. Ind Health. 2008;46:326–335. 16. Pejuskovic B, Lecic-Tosevski D, Priebe S, Toskovic O. Burnout syndrome among physicians—the role of personality dimensions and coping strategies. Psychiatr Danub. 2011;23:389–395. 17. Kokkinos MC. Job stressors, personality and burnout in primary school teachers. Br J Educ Psychol. 2007;77:229–243. 18. Narumoto J, Nakamura K, Kitabayashi Y, Shibata K, Nakamae T, Fukui K. Relationships among burnout, coping style and personality: study of Japanese professional caregivers for elderly. Psychiatry Clin Neurosci. 2008;62:174–176. 19. Fontana D, Abouserie R. Stress levels, gender and personality factors in teachers. Br J Educ Psychol. 1993;63:261–270. 165
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20. Schaufeli WB, Enzmann D. The Burnout Companion to Study and Practice: A Critical Analysis. London: Taylor and Francis; 1998. 21. Taylor GJ, Bagby RM, Parker JDA. Disorders of Affect Regulation: Alexithymia in Medical and Psychiatric Illness. Cambridge, UK: Cambridge University Press; 1997. 22. Sifneos PE. The prevalence of “alexithymic” characteristics in psychosomatic patients. Psychother Psychosom. 1973;22:255–262. 23. Freyberger H. Supportive psychotherapeutic techniques in primary and secondary alexithymia. Psychother Psychosom. 1977;28:337–342. 24. Bagby RM, Taylor GJ, Ryan D. Toronto alexithymia scale: relationship with personality and psychopathology measures. Psychother Psychosom. 1986;45:207–215. 25. de Vente W, Kamphuis JH, Emmelkamp PM. Alexithymia, risk factor or consequence of work-related stress? Psychother Psychosom. 2006;75:304–311. 26. Bratis D, Tselebis A, Sikaras C, et al. Alexithymia and its association with burnout, depression and family support among Greek nursing staff. Hum Resour Health. 2009;11:72. 27. Golbasi Z, Kelleci M, Dogan S. Relationships between coping strategies, individual characteristics and job satisfaction in a sample of hospital nurses: cross-sectional questionnaire survey. Int J Nurs Stud. 2008;45:1800–1806. 28. Lazarus RS, Folkman S. Stress, Appraisal and Coping. New York: Springer Publishing; 1984. 29. Folkman S, Lazarus RS. An analysis of coping in a middle-aged community sample. J Health Soc Behav. 1980;21:219–239. 30. LeSergent CM, Haney CJ. Rural hospital nurse’s stressors and coping strategies: a survey. Int J Nurs Stud. 2005;42:315–324. 31. Payne N. Occupational stressors and coping as determinants of burnout in female hospice nurses. J Adv Nurs. 2001;33:396–405. 32. Ceslowitz SB. Burnout and coping strategies among hospital staff nurses. J Adv Nurs. 1989;14:553–558. 33. Unal S, Karlidag R, Yologlu S. [Relationships between burnout, job satisfaction and life satisfaction in physicians]. Klinik Psikiyatri. 2001;4:113–118. [in Turkish] 34. Dikmetas E, Top M, Ergin G. [An examination of mobbing and burnout of residents]. T¨urk Psikiyatri Derg. 2011;22:137–149. [in Turkish] 35. Havle N, Ilnem MC, Yener F, Gumus H. [Burnout syndrome, job satisfaction among psychiatrists working in Istanbul and their relationships with different variables]. Dusunen Adam. 2008;21:4–13. [in Turkish] 36. Erol A, Saricicek A, Gulseren S. [Burnout in residents: association with job satisfaction and depression]. Anadolu Psikiyatri Dergisi. 2007;8:241–247. [in Turkish] 37. Dincer B, Ozaslan M, Kavasoglu T. [The Research of Socio-economic Development Level Ranking of Provinces and Regions in Turkey].
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Archives of Environmental & Occupational Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/vaeh20
Relationship of Burnout With Personality, Alexithymia, and Coping Behaviors Among Physicians in a Semiurban and Rural Area in Turkey a
b
Okan Taycan MD , Serap Erdoğan Taycan MD & Cihat Çelik MA
c
a
Adult Psychiatry Unit, Tokat State Hospital , Tokat , Turkey
b
Department of Psychiatry , Faculty of Medicine, Gaziosmanpasa University , Tokat , Turkey
c
Department of Psychology , Faculty of Arts and Sciences, Mus Alparslan University , Mus , Turkey Accepted author version posted online: 08 Mar 2013.Published online: 10 Dec 2013.
To cite this article: Okan Taycan MD , Serap Erdoğan Taycan MD & Cihat Çelik MA (2014) Relationship of Burnout With Personality, Alexithymia, and Coping Behaviors Among Physicians in a Semiurban and Rural Area in Turkey, Archives of Environmental & Occupational Health, 69:3, 159-166, DOI: 10.1080/19338244.2013.763758 To link to this article: http://dx.doi.org/10.1080/19338244.2013.763758
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Relationship of Burnout With Personality, Alexithymia, and Coping Behaviors Among Physicians in a Semiurban and Rural Area in Turkey Okan Taycan, MD; Serap Erdo˘ gan Taycan, MD; Cihat C ¸ elik, MA
ABSTRACT. This present study aimed to assess levels of burnout, to investigate the extent to which personal characteristics and coping behaviors are related to burnout, and to establish the predictors of burnout among physicians in a semiurban and rural area. A sample of 139 physicians was assessed using the Maslach Burnout Inventory, Eysenck Personality Questionnaire, Toronto Alexithymia Scale, and Ways of Coping Inventory. The level of burnout was found to be moderately higher than those reported among urban physicians. A forward stepwise multiple regression analysis indicated that neuroticism, occupation (specialist vs general practitioner), helpless, self-confident, and social support seeking approaches were predictors of burnout. The results showed that burnout was negatively related with problem-focused copping strategies, and positively with emotion-focused coping strategies. Fostering problem-focused coping strategies in physicians might be useful in the reduction of burnout. KEYWORDS: alexithymia, burnout, coping behavior, personality, physicians
B
urnout was first introduced by Freudenberger in 1974.1 The definition of burnout as we know today was formulated by Maslach and Jackson in 1982 as a prolonged response to chronic emotional and interpersonal stressors in the professions where individuals work mainly with humans such as physicians, mental health professionals, nurses, and teachers. It is a multidimensional concept consisting of emotional exhaustion, depersonalization, and personal accomplishment.2 Emotional exhaustion is the central quality of burnout and refers to feelings of being emotionally overextended and a notable reduction in one’s available emotional resources. Depersonalization is defined as behaving towards the caretakers without any emotion, as if they are not unique individuals. Personal accomplishment refers
to feelings of competence and successful achievement related to one’s work.3 Practicing as a physician requires intensive involvement with people; thus, physicians are considered to be vulnerable to experiencing burnout.4,5 Burnout in physicians is crucial not only because it potentially causes health problems such as fatigue, insomnia, and physical exhaustion but also because it influences patient satisfaction and treatment outcomes. Therefore, prevention of burnout in physicians is essential towards improving the quality of patient care.6,7 The issue of which factors influence the development of burnout is controversial among researchers. Whereas some researchers point to the importance of organizational factors such as stressful conditions at work, others refer to interpersonal variables such as problems concerning relationships
Okan Taycan is with the Adult Psychiatry Unit, Tokat State Hospital, Tokat, Turkey. Serap Erdo˘gan Taycan is with the Department of Psychiatry, Faculty of Medicine, Gaziosmanpasa University, Tokat, Turkey. Cihat C ¸ elik is with the Department of Psychology, Faculty of Arts and Sciences, Mus Alparslan University, Mus, Turkey. 2014, Vol. 69, No. 3
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with colleagues.6,8–11 According to these views, environmental factors pertaining to the workplace play a major role in the development of burnout. However, these factors could not adequately explain why under the same working conditions, one individual burns out, whereas another does not.12 Personality plays a significant role in how people perceive stress and may influence their way of coping, which in turn may influence the development of burnout.13 Piedmont indicated that even when situational variables were controlled, personality continued to account for a significant portion of the variance in burnout scores.14 Previous studies showed that some personality traits such as neuroticism, extraversion, or alexithymia may increase the sense of stress and contribute to the development of burnout.12,15–18 Fontana and Abouserie found that stress level was positively correlated with psychoticism and neuroticism but correlated negatively with extraversion. They found that extraversion and neuroticism were the best predictors of stress levels.19 Similarly, Schaufeli and Enzmann indicated that neuroticism was one of the strongest personality correlates of burnout.20 Alexithymia is characterized by impoverishment of fantasy, a poor capacity for symbolic thought, and difficulties in identifying and expressing feelings.21 It is, by definition, considered to be a stable personality trait.22 However, some authors claimed that alexithymia could be a temporary feature rather than a personality trait.23,24 In both cases, alexithymic individuals do not only have difficulties in identifying one’s own feelings but also have difficulties in identifying emotions of others, resulting in an inability to build intimate relationships. Deteriorated relations in the work climate may especially predispose individuals with alexithymia to stressrelated health problems, including burnout. Several studies have yielded the interrelationship between alexithymia and burnout.25,26 Burnout is also defined as an inability to cope with emotional stress at work. It is well documented that reactions to stress can vary among individuals depending on the coping strategies used.27 Accordingly, coping behaviors of individuals contribute to the explanation of why exposure to the same stressors may cause burnout in some subjects but not in others.16 Two types of coping were identified by Lazarus and Folkman: problem-focused coping, which attempts to manage or alter the problem causing distress; and emotionfocused coping, consisting of attempts to reduce the negative feelings associated with the threat rather than alter the source of the threat.28 Both types of coping are used in most situations.29,30 However, it was also claimed that the use of problem-focused coping strategies may prevent burnout, whereas emotion-focused strategies contribute to burnout.31 Several studies have shown the interrelationship between burnout and coping strategies with stress.15,16,18,31,32 Turkey has a highly complex, fairly organized and underfunded health care system, which imposes extra stress to work life of physicians and contributes to burnout.4 Research investigating burnout among physicians in this country has mostly taken place in urban areas.4,33–36 Little is known about 160
burnout and related factors among physicians working at semiurban and rural areas in Turkey. However, it has been reported that rural physicians are more prone to experiencing burnout because they face unique practice and personal stressors, many of which are beyond their control, such as excessive clinical workload, professional and social isolation, difficulty taking time off, and heavy on-call requirements.5 This present study aimed (a) to assess levels of burnout; (b) to investigate the extent to which personal characteristics and coping behaviors are related to burnout; and (c) to establish the predictors of burnout among physicians working in a semiurban and rural area. To our knowledge of the literature, a study focusing on burnout and relationships with personality and coping behaviors among semiurban and rural physicians has not been done before. We expected to find (a) high levels of burnout in semiurban and rural physicians; (b) a positive relationship between neuroticism, alexithymia, and burnout; and (c) that physicians who experience less burnout would more likely use problem-focused strategies to cope with stress. METHODS Sample selection and procedures The survey was conducted on all physicians working in the province of Mus located in the eastern Turkey. Mus has a population density of 56 people per square kilometer, whereas the population density of Turkey is 88 people per square kilometer. It is one of the least developed provinces in Turkey. According to a report indicating socioeconomic development ranking of provinces in Turkey published by the State Planning Organization, Mus was indicated to be the poorest and the least developed province of 81 provinces in the country.37 Although there are some population centers of more than 10,000 people in the province, taken both the demographic properties and socioeconomic conditions of the region into consideration, Mus is considered to be a combination of mostly rural and partly semiurban areas. The study was approved by the institutional review board of Inonu University, Malatya, and the Mus Provincial Directorate of Health. Physicians who were eligible for the study were individually invited to participate in the study after the nature of the study and methods for ensuring confidentially were explained by the researcher. Physicians were requested to complete the forms and return them either in person or by mail. All participants provided written informed consent. There were 207 physicians working in the province in August 2008 (97 specialists, 110 general practitioners). Because the study concerned actual work conditions during clinical practice, we excluded 12 physicians who worked exclusively as administrators—they were either provincial health directors (n = 2, 0.9%) or head physicians of hospitals (n = 10, 4.8%). Of the 195 physicians who were eligible for the study, 12 did not wish to participate or did not return the questionnaires (6.1%) and 44 (22.5%) could not be reached because Archives of Environmental & Occupational Health
they were either on vacation or sick leave when the study was conducted. Consequently, the response rate was 71.2%; the final sample of the study consisted of 139 physicians. This present study is a part of a larger study on mental health of semiurban and rural physicians. Measures Participants provided sociodemographic data and completed a series of self-report questionnaires, including the Maslach Burnout Inventory, the Eysenck Personality Questionnaire Revised—Abbreviated Form, the Toronto Alexithymia Scale-20, and the Ways of Coping Inventory.
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Sociodemographic Data Form This form was developed by researchers to obtain data related to demographic and organizational characteristics of the physician sample, including age, gender, marital status, occupation, years in practice, satisfaction with salary, and daily number of patients. Maslach Burnout Inventory (MBI) The MBI—Human Services Survey was used to measure frequency of burnout. The scale consists of 22 items constituting 3 subscales: emotional exhaustion, depersonalization, and personal accomplishment. The higher the emotional exhaustion and depersonalization score and lower the personal accomplishment score, the more a physician would be suffering from burnout.2 The Turkish translation of MBI has been shifted to 5-point Likert style from the original 7-point Likert style, since it was concluded that the former was more appropriate for Turkish culture. Each subscale score can be categorized as low, moderate, or high burnout as defined by normative data for the 7-point scale version. However, normative data for these categories were unavailable for the 5-point Likert style Turkish version. Therefore, only mean scores of each subscale were used in this study. The Turkish translation of the MBI has been shown to be valid and reliable in Turkish participants. Cronbach’s alpha scores were .83 for emotional exhaustion, .65 for depersonalization, and .72 for personal accomplishment.38 Eysenck Personality Questionnaire Revised—Abbreviated Form (EPQR-A) Personality traits were measured using one of a series of personality inventories developed by Eysenck and Eysenck.39 The EPQR-A has 24 items, 6 for each of the traits of neuroticism, extraversion, and psychoticism, and 6 for the lie scale.40 Extraversion represents sociability, liveliness, and impulsivity; neuroticism represents emotional instability and anxiousness; psychoticism represents tough-mindedness, aggressiveness, coldness, and egocentricity; and the lie scale represents unsophisticated dissimulation and social naivety or conformity.39 The psychoticism subscale was found to be correlated with a variety of traits such as impulsiveness, 2014, Vol. 69, No. 3
lack of cooperation, oral pessimism, rigidity, low superego controls, low social sensitivity, low persistence, lack of anxiety, and lack of feelings of inferiority. Howarth criticized the lack of clarity related to this concept, as psychoticism was the least univocal compared with neuroticisim and extraversion.41 This issue raises the question of what psychoticism really measures. In order to clearly focus on personality traits that are well-defined and have been extensively studied, only neuroticism and extraversion subscales were selected to be used in our survey. The Turkish version of the EPQR-A was modified by Karancı et al.42 Cronbach’s alpha scores for extraversion, neuroticism, psychoticism, and lie scales were .78, .65, .42, and .64, respectively. Toronto Alexithymia Scale-20 (TAS-20) Alexithymia was assessed with the 20-item TAS, which consists of 3 subscales: difficulty in identifying feelings, difficulty in describing feelings, and externally oriented thinking.43 The Turkish translation of the scale revealed good internal reliability (Cronbach’s alpha = .76) but did not support the original TAS-20 3-factor structure.44 Therefore, only the total score was used in this study. Ways of Coping Inventory (WCI) The WCI was developed by Lazarus and Folkman in 1980 and has 30 items pertaining to 5 coping behaviors or approaches: self-confidence, optimistism, social support seeking, helplessness, and yielding.29 Each subscale is scored separately. A higher score indicates that the coping strategy is more often used. Self-confident, optimistic, and social support seeking approaches are evaluated as effective ways of coping with stress, representing problem-focused coping strategies; the other 2 approaches (helpless and yielding approaches) are evaluated as ineffective/emotional directed ways of coping with stress, representing emotion-focused coping strategies. A Turkish version of the WCI was found to have satisfactory reliability and validity characteristics.45 Cronbach’s alphas of subscales were .69 for self-confident approach, .63 for optimistic approach, .72 for social support seeking approach, .67 for helpless approach, and .68 for yielding approach.45 Statistical analysis All discrete (or continuous) variables were found to be normally distributed based on the Kolmogorov-Smirnov test. The chi-square for categorical variables and independent t tests for continuous measures were used to test the statistical significance of differences between general practitioners and specialists on demographic and organizational characteristics. Bivariate relationships between continuous variables were examined with Pearson product moment correlations. The independent associations between each burnout dimension (emotional exhaustion, depersonalization, personal accomplishment) and personality traits 161
(extraversion, neuroticism, alexithymia) and coping behaviors (self-confident, optimistic, social support seeking, helpless, and yielding approaches) were assessed using forward stepwise multiple regression, controlling for age, gender, and occupation. The variables that were added to the regression were chosen automatically by SPSS (SPSS, Chicago, IL, USA). Variance inflation factors were calculated to check for multicollinearity among the predictors in the regression analyses. All analyses were conducted with SPSS version 11.5, and all statistical tests were 2-sided with a p < .05 significance level.
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RESULTS Seventy-six (54.7%) of 139 participants in the study were general practitioners. The mean age of the sample was 31.05 ± 4.84 years. Of the subjects, 93 (66.9%) were male and 72 (51.8%) were married. The mean years in practice were 6.07 ± 4.71. Table 1 shows the comparison of demographic and organizational characteristics in specialists and general practitioners. Accordingly, specialists and general practitioners differed significantly in terms of age, marital status, years in practice, daily number of patients, and salary satisfaction. Specialists were more likely older, married, satisfied with their salary, and to have a greater daily number of patients than general practitioners. It was concluded that the significant difference in years of practice between specialists and general practitioners was related to the age difference. The difference in gender was not statistically significant.
The mean score of emotional exhaustion for the whole sample was 14.91 ± 7.02, depersonalization was 5.80 ± 3.33 and personal accomplishment was 20.35 ± 3.85. Table 2 shows the correlations of burnout dimensions with demographic and organizational characteristics of the sample. Depersonalization scores of specialists were significantly higher than those of general practitioners. Physicians who have more than 50 patients daily had significantly higher scores on depersonalization and lower scores on personal accomplishment. No statistically significant difference was found between MBI subscale scores of physicians obtained according to their age, marital status, years of practice, and level of satisfaction with the salary. The bivariate correlations of burnout dimensions with personality traits, alexithymia, and coping behaviors are shown in Table 3. Of the personality variables, neuroticism was positively correlated with emotional exhaustion and depersonalization, and negatively correlated with personal accomplishment. Extraversion was negatively correlated with emotional exhaustion and depersonalization, and positively associated with personal accomplishment. Alexithymia was significantly and positively correlated with emotional exhaustion and depersonalization. No statistically significant relation was found between alexithymia and personal accomplishment. In terms of coping behaviors, emotional exhaustion and depersonalization were negatively correlated with problem-focused coping strategies, including self-confident and optimistic approaches; positively correlated with emotion-focused coping strategies, including helpless approach. Personal accomplishment was positively correlated with problem-focused coping strategies
Table 1.—-Comparison of Demographic and Organizational Characteristics in Specialists and General Practitioners
Characteristic Gender (male) n % Age (years) Mean SD Marital status (married) n % Years in practice Mean SD Daily number of patients (≥50 patients) n % Satisfaction with the salary (unsatisfied) n % ∗p
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Specialists (n = 63)
General practitioners (n = 76)
42 66.6%
51 67.2%
33.96 3.60
28.63 4.40
43 68.2%
29 38.1%
9.80 3.00
2.98 3.47
45 71.4%
40 52.6%
37 58.7%
60 78.4%
Statistical analysis χ 2 = 0.00 t = −7.71∗∗∗ χ 2 = 12.49∗∗∗ t = −12.23∗∗∗ χ 2 = 5.12∗ χ 2 = 6.67∗
< .05; ∗∗∗ p < .001.
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Table 2.—-Correlations of Burnout Dimensions With Demographic and Organizational Characteristics of the Sample Characteristic
Emotional exhaustion
Depersonalization
Personal accomplishment
Gender Age Marital status Occupation General practitioner Specialist
t = 0.76 r = .06 t = 1.04 t = −1.92
t = −0.76 r = .11 t = 0.20
t = 1.73 r = .01 t = 0.02 t = 0.45
Years in practice Daily number of patients ≤50 patients >50 patients
r = .07 t = −1.88
Satisfaction with the salary
t = 1.40
M = 5.02, SD = 3.28 M = 6.74, SD = 3.16 t = −3.12∗∗ r = .16 M = 4.92, SD = 2.94 M = 6.36, SD = 3.45 t = −2.53∗ t = 0.43
r = .00 M = 21.16, SD = 3.61 M = 19.83, SD = 3.92 t = 2.00∗ t = −0.00
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Note. r = bivariate Pearson correlation. ∗ p < .05; ∗∗ p < .01.
(self-confident, social support seeking, and optimistic approaches) and negatively correlated with emotion-focused coping strategies (helpless, and yielding approaches). The most frequently used coping strategy was reported to be selfconfident approach (2.07 ± 0.45) and the least frequently used was the yielding approach (0.88 ± 0.44). Table 4 shows the stepwise multiple regression model of concurrent independent correlates of burnout dimensions. Each burnout dimension (emotional exhaustion, depersonalization, personal accomplishment) was regressed on demographic characteristics (age, gender, occupation), personality traits (extraversion, neuroticism, alexithymia), and coping behaviors (self-confident, social support seeking, optimistic, helpless, and yielding approaches). Emotional exhaustion was predicted by neuroticism, occupation (being a special-
ist), and helpless approach, which all together accounted for 26% of the variance. Depersonalization was predicted by neuroticism, occupation (being a specialist), and selfconfident approach, which all together accounted for 23% of the variance. Self-confident approach and social support seeking approach were predictors of personal accomplishment, which explained 23% of the variance. COMMENT The MBI scores of our study were consistent with those obtained from the largest study on burnout among 1750 urban, semiurban, and rural physicians in Turkey, as the emotional exhaustion, depersonalization, and personal accomplishment mean scores were 15.48, 5.51, and 22.06, respectively (MBI
Table 3.—-Bivariate Correlations of Burnout Dimensions With Personality Traits, Alexithymia, and Coping Behaviors Variable Burnout Emotional Exhaustion Depersonalization Personal Accomplishment Personality traits Extraversion Neuroticism Alexithymia Coping behaviors Self-confident approach Social support seeking approach Optimistic approach Helpless approach Yielding approach ∗p
Emotional exhaustion
Depersonalization
Personal accomplishment
— .64∗∗∗ −.28∗∗∗
.64∗∗∗ — −.38∗∗∗
−.28∗∗∗ −.38∗∗∗ —
−.20∗ .43∗∗∗ .26∗∗∗
−.25∗∗ .35∗∗∗ .29∗∗∗
.27∗∗∗ −.28∗∗∗ −.06
−.32∗∗∗ −.04 −.35∗∗∗ .34∗∗∗ .12
−.31∗∗∗ −.12 −.33∗∗∗ .25∗∗ .08
.45∗∗∗ .21∗ .33∗∗∗ −.20∗ −.20∗
< .05; ∗∗ p < .01; ∗∗∗ p < .001.
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Table 4.—-Forward Stepwise Multiple Regression Model of Concurrent Independent Correlates of Burnout Dimensions‡ Dependent variable Emotional exhaustion
Depersonalization
Personal accomplishment
Independent variable
R2
Standardized beta (β)
t
Neuroticism Occupation (0 = general practitioners; 1 = specialists) Helpless approach Neuroticism Occupation (0 = general practitioners; 1 = specialists) Self-confident approach Self-confident approach Social support seeking approach
.19 .22 .26 .12 .20 .23 .20 .23
.36 .19 .19 .30 .26 −.18 .44 .18
4.51∗∗∗ 2.56∗ 2.42∗ 3.76∗∗∗ 3.52∗∗ −2.32∗ 5.89∗∗∗ 2.49∗
‡Variables in the model: demographic factors (age, gender, occupation) personality traits (extraversion, neuroticism, alexithymia), and coping behaviors
(self-confident, optimistic, social support seeking, helpless, and yielding approaches). < .05; ∗∗ p < .01; ∗∗∗ p < .001.
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∗p
scores of urban, semiurban, and rural physicians were not analyzed separately).46 Since the Turkish translation of MBI has 5-point Likert style instead of 7-point Likert style in the original scale, it did not allow us to compare the rough results obtained from MBI with those from the international literature. A number of studies from Turkey have reported higher burnout scores in psychiatrists, and in physicians working in university hospitals than those obtained in our study.35,47 Such higher scores could be the result of differences in the physician samples. Indeed, it has been indicated that psychiatrists are vulnerable to experiencing burnout, more so than other physicians.48 Two other studies of 598 and 384 urban physicians consisting of both specialists and general practitioners reported lower burnout scores, indicating that semiurban and rural physicians in our sample were more susceptible to experiencing burnout than their urban counterparts.4,33 Alexithymia showed a positive correlation with both emotional exhaustion and depersonalization, suggesting that physicians who have difficulties in verbalizing their feelings were more susceptible to burnout. Several previous studies supported this correlation.25,26,49 It was hypothesized that alexithymia is a predisposing factor to burnout due to inadequate coping with occupational stress.49 Indeed, the significant correlation between alexithymia and both emotional exhaustion and depersonalization disappeared after controlling for other variables, including coping strategies, with stress in our regression analysis. This finding may support that dysfunctional coping strategies mediated the effect of alexithymia on burnout. However, the cross-sectional design of our study does not allow us to infer causality. This direction of effect needs to be clarified with further studies that use a prospective design. The results of 3 separate stepwise multiple regression analyses that were conducted regressing each burnout dimension on physicians’ demographics, personality characteristics, and coping behaviors showed that age, gender, alexithymia, and among the coping strategies optimistic and 164
yielding approaches revealed no statistically significant contribution to any of 3 burnout dimensions. The regression models predicting emotional exhaustion and depersonalization showed similar patterns. Neuroticism was identified as the best predictor of both emotional exhaustion and depersonalization, which explained 19% and 12% of the variance, respectively. Neuroticism refers to the general emotional instability of the participants, and identifies individuals prone to psychological distress and maladaptive coping responses. It was hypothesized that both emotional exhaustion and depersonalization scales should have a high association with neuroticism.14 In this respect, our result is consistent with a number of studies that concluded that neuroticism was robustly associated with both emotional exhaustion and depersonalization.12,14,15,18,19 Occupation (specialist vs general practitioner) was also an independent predictor of both emotional exhaustion and depersonalization. It was found that specialists had a significantly greater daily number of patients than general practitioners in our study. This finding may potentially contribute to higher levels of burnout among specialists. Besides, semiurban and rural specialists in our sample seem more likely to deal with high work demands without adequate resources, feelings of isolation, and a lack of feedback. Exposure to such occupational stressors could be responsible for having higher levels of emotional exhaustion and depersonalization. Reporting a helpless approach (emotion-focused coping strategy) was another predictor of emotional exhaustion indicating that as physicians experienced higher emotional exhaustion, they relied more on emotion-focused coping strategies. It seems that emotion-focused coping strategies make physicians more prone to emotional exhaustion. There are several previous studies that are consistent with this finding.16,18,32 In a longitudinal study, Isaksson Ro et al indicated that reduction in emotion-focused coping and job stress preceded reduction in emotional exhaustion.50 Reporting a selfconfident approach (problem-focused coping strategy) was found to be a predictor of both depersonalization and personal Archives of Environmental & Occupational Health
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accomplishment. This seems to be a contradiction to our hypothesis at first glance, as problem-focused coping strategies were expected to play an important role in the prevention of burnout. However, the correlation between depersonalization and reporting a self-confident approach was negative, indicating that a higher depersonalization score was associated with less problem-focused coping strategy. These findings are in accord with a recent study in which a self-confident approach was found to be negatively correlated with depersonalization and positively correlated with personal accomplishment.16 The regression model predicting personal accomplishment showed a very different pattern. Neither demographic characteristics nor personality significantly predicted personal accomplishment. Problem-focused coping strategies (self-confident approach and social support seeking approach) were found to be significant predictors of personal accomplishment. This implies that physicians who had higher scores on personal accomplishment more likely use problem-focused coping strategies, which may help to prevent burnout. This finding is supported by a number of studies.26,31 Previous studies reported a negative correlation between stress and social support indicating that as stress levels rise, individuals rely more on social support in order to decrease their feelings of stress.30,51 Accordingly, our results showed that seeking social support as a coping strategy against stress may have contributed to an increase in feelings of achievement in physicians. However, it is not possible to draw any conclusions about the direction of causality from our findings. Further longitudinal studies are needed to clarify this issue. In terms of the limitations of our study, the first is the cross-sectional nature of the design, making it difficult to ascertain causality. Another limitation is the lack of an urban physician sample for comparison. Studies on burnout among urban physicians in Turkey lead us to suspect that urban physicians are not as burned out as their semiurban and rural colleagues.4,33 CONCLUSIONS In conclusion, our results supported that in addition to external factors such as occupational and organizational characteristics, internal factors such as personality traits and the way how physicians cope with stress play a significant role to experiencing burnout among semiurban and rural physicians. Particularly being a specialist, neuroticism and emotionfocused coping strategies may be predisposing factors to burnout. Our results showed that burnout was negatively related with problem-focused coping strategies, and positively related with emotion-focused coping strategies, suggesting that problem-focused copping strategies might be useful in preventing or at least reducing burnout. Furthermore, individuals with alexithymic features could be prone to experiencing burnout because of their inadequate capacity to cope with stress. In the light of these results, as personality is considered to be a rather stable construct, interventions focused 2014, Vol. 69, No. 3
on the improvement of stress coping strategies would be more helpful in the prevention of burnout in semiurban and rural physicians. Taken together, these findings contribute to the limited extant literature attempting to explain burnout among physicians in nonurban settings and highlight the importance of associations between burnout, personality, and coping behaviors. Future studies may evaluate self-care and problem-focused interventions intended to improve provider mental health and patient care in less urban settings. ********** The authors would like to express their gratitude to Tomas Jurkic (Concordia University, Montreal, Canada) for his constructive comments on earlier drafts of the paper. For comments and further information, address correspondence to Okan Taycan, MD, Kasikcibagları Mahallesi, Cihangir 2. Sokak, Tokkent Sitesi B Blok No: 5, Tokat, Turkey. E-mail: [email protected]
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