Anxiety, burnout and coping styles in general hospital staff exposed to workplace aggression: a cyclical model of burnout and vulnerability to aggression

Although an increasing problem, the aggression ( physical assault, threatening behaviour and verbal aggression) directed toward general hospital staff rather than staff in psychiatric institutions has not been widely investigated. The present study first compared anxiety, coping styles and burnout according to the frequency of aggressive experiences. Second, a sub-sample was examined to determine any immediate after-effects from aggressive encounters. Healthcare staff ( n = 375) across professions completed the State-Trait Anxiety Inventory, the Maslach Burnout Inventory and the Coping Responses Inventory, which were analysed according to the type and frequency of aggression experienced within the preceding year. There were no significant differences in levels of anxiety or in coping styles. However, significant differences were determined in levels of burnout. Emotional exhaustion and depersonalization were significantly higher in those staff more frequently victimized suggesting that aggressive encounters might lead to an increase in burnout. Equally, the converse might be true. Therefore, a cyclical model is put forward in which we propose that elevated levels of burnout from all sources might increase vulnerability to victimization. Increases in emotional exhaustion lead directly to an increase in depersonalization as a coping mechanism, which subsequently manifests as a negative behavioural change toward patients, thus rendering staff more vulnerable to further aggression.     

The association between job skill discretion,decision authority and burnout

This paper reports on the relationship between dimensions of control (skill discretion and decision authority) and burnout (emotional exhaustion, depersonalization, and reduced personal accomplishment) among 164 human service workers. It examines the differential influence of job demands, control (skill discretion and decision authority) and social support (supervisor, co-workers, others) on each burnout dimension. Then it examines the moderating effects of higher skill discretion, higher decision authority, and higher social support on burnout. Low skill discretion was found to be associated with high emotional exhaustion and depersonalization and low personal accomplishment. The effects of decision authority were not statistically significant. High job demands were associated with high emotional exhaustion only. Social support (supervisor, co-worker, and others) was not associated with burnout when demographic variables and job characteristics were controlled for. Neither dimension of control moderated the impact of high job demands on burnout. Social support did not moderate the impact of high demands, low skill discretion, or low decision authority on any burnout dimension. The full model explained 44% of the variance in emotional exhaustion, 25% in depersonalization, and 42% in personal accomplishment. Despite its limitations, the study suggests that the Job Demand-Control model may provide a useful theoretical foundation for the study of burnout, but that the control dimensions need to be evaluated independently since they appear to be differentially related to the burnout dimensions.     

Burnout in Greek teachers: Main findings and validity of the Maslach Burnout Inventory

Abstract

The factorial structure of the Maslach Burnout Inventory (Maslach and Jackson 1986) was investigated in a sample of 220 Greek teachers and was found to be similar to that reported by Maslach and Jackson. A job satisfaction measure was employed for the investigation of the discriminant validity of the burnout measure. Correlations between job satisfaction and the three burnout dimensions were found to be low to moderate. It is suggested that the relationship and the degree of overlap between emotional exhaustion and job satisfaction require further examination. Greek teachers reported lower levels of burnout on the emotional exhaustion and depersonalization scales than teachers in other countries. Finally, younger teachers experienced more emotional exhaustion than older ones and primary education teachers experienced more personal accomplishment and less depersonalization than their counterparts in secondary education.     

Four-stage process model of the core factors of burnout: The role of work stressors and work-related resources

The impact of work stressors and work-related resources on emotional exhaustion and depersonalization, as the two core factors of burnout, is investigated. According to the German Action Regulation Theory work stressors are conceptualized as regulation problems that lead to work stress in terms of additional effort (e.g. working longer hours), increased intensity of effort (e.g. working at a faster pace), and risky action (e.g. by neglecting safety rules). Consequently, an extended process model consisting of objective work stressors, work stress, emotional exhaustion and depersonalization is proposed. Nurses from three general hospitals (N=482) provided data for evaluating this model. Complete mediation of work stress and emotional exhaustion were analysed by hierarchical regression analysis. The overall model was tested by structural equation analysis in two steps; in the first step the basic model was analysed while in the second step the model was extended by autonomy as a work-related resource. The process model could be confirmed with respect to: (1) the mediating function of work stress and emotional exhaustion, and with regard to (2) the direct impact of autonomy as a work-related resource on work stressors but not on emotional exhaustion and depersonalization. Methodological considerations and implications for work design and burnout prevention are discussed.     

Cognitive model of patient aggression towards health care staff: The patient's perspective

Abstract

Aggression towards health care staff has become the focus for research as well as for government intervention. Negative effects upon staff and organizations have been established, yet few detailed explanations are offered for this aggression, and none represents the patient's perspective. This paper presents a model from the patient's perspective that takes account of situational variables, while also focusing upon patient cognitions. It also considers physiological responses related to arousal that might underpin aggression in an anxiety-provoking situation. In a previous study the frequency with which aggression was preceded by some anxiety-provoking event and the extent to which assailants displayed diminished cognitive processing were established; these were incorporated into the model. Increased anxiety commonly experienced by patients can have a negative effect upon cognitive processing. Anxiety generates a hyper-vigilance for threatening stimuli, induces selective attentional bias for threat, and causes a narrowing of attention, thus reducing cues and information upon which to make accurate appraisals and attributions. With such impairments, patients may make negative rather than positive attributions regarding actions of staff, which are frequently anxiety provoking. Thus, patients perceive staff behaviour as threatening rather than benign, and in the absence of positive attributions it will invoke an aggressive response. What health care staff perceive as aggression may be seen by patients as a defence against perceived attack. Changes in policy that take this into account may reduce future aggressive incidents.     

Performance and burnout in intensive care units

Abstract

The relationship between three different performance measures and burnout was explored in 20 Dutch Intensive Care Units (ICUs). Burnout (i.e. emotional exhaustion and depersonalization) proved to be significantly related to nurses' perceptions of performance as well as to objectively assessed unit performance. Subjective performance measures relate negatively to burnout levels of nurses, whereas an objective performance measure relates positively to burnout. Furthermore, subjectively assessed personal performance (i.e. personal accomplishment) is more strongly related to burnout than subjectively assessed unit performance. A model test of the relationship between both types of subjective performance and burnout reveals that nurses' perception of unit performance is indirectly related to burnout through perception of personal performance. This model holds similarly for objectively well- and poor-performing ICUs.     

The conceptualization and measurement of burnout: Common ground and worlds apart

In this edition of Work & Stress, Kristensen and his colleagues critically discuss the Maslach Burnout Inventory (MBI) and present an alternative, more general instrument to measure burnout that exclusively focuses on exhaustion. Here we critically examine their reasons for developing a new burnout measure, as well as the theoretical foundations of this measure. Whereas we agree with Kristensen et al.'s remarks concerning the availability and item wording of the MBI, we do not share their concerns regarding its theoretical underpinnings. In our view, burnout should be conceptualized as a primarily work-related syndrome of (at least) exhaustion and depersonalization/cynicism. The MBI would seem to fit that conceptualization very well.     

Relationships between personality variables and burnout: A meta-analysis

Abstract

Most burnout research has focussed on environmental correlates, but it is likely that personality factors also play an important part in the development of burnout. Previous meta-analyses, however, have been limited in scope. The present meta-analysis examined the relationship between personality and three dimensions of the Maslach Burnout Inventory (MBI): emotional exhaustion, depersonalization, and personal accomplishment. Consistent with our hypotheses, self-esteem, self-efficacy, locus of control, emotional stability, extraversion, conscientiousness, agreeableness, positive affectivity, negative affectivity, optimism, proactive personality, and hardiness, each yielded significant relationships with burnout. Type A Personality, however, was only related to personal accomplishment. Furthermore, regression analysis found that core self-evaluations, the Five-Factor Model personality characteristics, and positive and negative affectivity explained significant variance in each of the burnout dimensions. Finally, moderator analyses found several instances in which the strength of personality–burnout relationships depended upon whether burnout was assessed with the Human Services Survey of the MBI or the General Survey version of the MBI. It is concluded that employee personality is consistently related to burnout. Given the practical importance of employee burnout, it is recommended that personality variables be included as predictors in future research on burnout.     

Lifestyle habits,substance use and predictors of job burnout in professional working women

Abstract

This study explores differences in self-reported lifestyle habits, substance use (alcohol, drugs and smoking) and predictors of job burnout in a sample of 879 professional working women employed in dental health ofices in a cross-sectional design. Job burnout was measured using the Maslach Burnout Inventory (MBI) and self-reported substance use and lifestyle habits were assessed using the Stress Assessment Profile. Self-reported drinking, smolung and drug use were only modestly correlated with each other in this sample. Employed women with higher levels of drinking reported significantly lower quality overall lifestyle practices, eating/nunition habits, and more frequent use of avoidant coping strategies in the face of work and life hassles compared to non-drinkers. Women who smoked also reported significantly lower overall lifestyle practices and eating/nutrition habits. Those who reported using drugs for recreational purposes reported significantly greater hassles, poorer lifestyle habits, a less hardy outlook on life, and more frequent use of dysfunctional coping strategies. Although women who reported using drugs experienced significantly higher interpersonal burnout (depersonalization) compared to non-drug users, in general, self-reported substance use was not significantly related to job burnout. After controlling for age and psychological distress, perceived stress, type A behaviour, cognitive hardiness and lifestyle habits significantly contributed to predictions of job burnout in multiple regression analyses. Despite methodological limitations, the prevalence of substance use found in this study supports previous research findings. Professional working women who practise poor lifestyle and health habits appear to be at risk of experiencing job burnout.     

Gender differences in the effects of coping assistance on the reduction of burnout in academic staff

This study examined gender differences in the effectiveness of five sources of coping assistance to reduce dissatisfaction and emotional exhaustion among 403 female and 664 male academic staff of a Dutch university. It was hypothesized that support at work ((1) socio-emotional aid from the supervisor and colleagues, (2) a supportive climate in the department, and (3) practical assistance in the department) and support at home ((4) socio-emotional aid from the spouse, and (5) practical assistance from the spouse) would reduce dissatisfaction and burnout, and that women especially would benefit from these coping assistance measures. Using moderated regression analyses, the results showed that coping assistance from a supervisor and colleagues is an important measure to reduce both dissatisfaction and emotional exhaustion. Further, a supportive departmental climate and practical assistance in the department reduced emotional exhaustion and especially female academic staff benefited from these types of coping assistance at the aggregate level. However, contrary to expectations, such beneficial effects were not found for both socio-emotional aid and practical assistance from the spouse.     

Work-related and individual determinants of the three burnout dimensions

Applying the Conservation of Resources (COR) theory as a framework, this study among Dutch nurses (n=156) first tested whether work-related demands, resources and self-esteem were differentially associated with the three burnout dimensions (emotional exhaustion, personal accomplishment and depersonalization), respectively. In addition, the current study investigated the interrelationships between the burnout dimensions and the hypothesized moderating effect of self-esteem. As expected, emotional exhaustion was primarily associated with job demands (i.e. work overload) and-to a slightly lower extent-with resources such as social support and self-esteem. In contrast, but also according to the authors' predictions, depersonalization and personal accomplishment were not associated with job demands. Emotional exhaustion was, as predicted, an important correlate of depersonalization, whereas reduced personal accomplishment was negatively associated with self-esteem and with quality of work content, a resource. In line with earlier findings but contrary to some recent propositions, reduced personal accomplishment was positively associated with depersonalization. Finally, self-esteem did not moderate the relationships between the selected work factors and the burnout dimensions. The limitations of the study are discussed and directions for future research are proposed.     

The relationship between burnout and organizational commitment in two samples of health professionals

Relationships between dimensions of burnout and employee commitment to the organization were tested in two hospital samples, using structural equations analysis. Whereas burnout has typically been assumed to be a predictor of organizational commitment, the present data provided support for the converse hypothesis, that low commitment contributes to the experience of burnout. Specifically, in a sample of nurses (n = 197), commitment showed direct effects on emotional exhaustion and depersonalization, and a weaker indirect effect (via exhaustion) on depersonalization. A similar pattern of effects emerged in a sample of laboratory technicians from the same organization (n = 110), although in this case the direct linkage between organizational commitment and depersonalization was not statistically significant. Implications for organizational efforts to reduce burnout are discussed.     

The association between job skill discretion, decision authority and burnout

This paper reports on the relationship between dimensions of control (skill discretion and decision authority) and burnout (emotional exhaustion, depersonalization, and reduced personal accomplishment) among 164 human service workers. It examines the differential influence of job demands, control (skill discretion and decision authority) and social support (supervisor, co-workers, others) on each burnout dimension. Then it examines the moderating effects of higher skill discretion, higher decision authority, and higher social support on burnout. Low skill discretion was found to be associated with high emotional exhaustion and depersonalization and low personal accomplishment. The effects of decision authority were not statistically significant. High job demands were associated with high emotional exhaustion only. Social support (supervisor, co-worker, and others) was not associated with burnout when demographic variables and job characteristics were controlled for. Neither dimension of control moderated the impact of high job demands on burnout. Social support did not moderate the impact of high demands, low skill discretion, or low decision authority on any burnout dimension. The full model explained 44% of the variance in emotional exhaustion, 25% in depersonalization, and 42% in personal accomplishment. Despite its limitations, the study suggests that the Job Demand-Control model may provide a useful theoretical foundation for the study of burnout, but that the control dimensions need to be evaluated independently since they appear to be differentially related to the burnout dimensions.     

Is there a relationship between burnout and objective performance? A critical review of 16 studies

Previous research has suggested that high levels of burnout lead to impaired functioning on the job. However, as this research has usually relied on self-reported performance, it is imperative to examine whether this association is also confirmed when using “objective” performance data (e.g., supervisor reports). This study reviewed previous research on the associations between burnout (exhaustion, depersonalization, and personal accomplishment) and various types of objective performance. A systematic literature search identified 16 studies dealing with the burnout-performance relationship. These studies showed the wide variety of approaches that are used to study burnout and objective performance. Using data from these 16 studies, a meta-analysis was conducted to obtain mean correlations. The meta-analytical correlations between exhaustion and in-role behaviour (based on five studies), organizational citizenship behaviour (OCB; five studies), and customer satisfaction (two studies) were -.22, -.19, and -.55, respectively, underlining the practical relevance of burnout research for organizational performance. The evidence for the relationships between depersonalization, personal accomplishment, and performance was inconclusive. Future research should focus on valid indicators of job performance, should more often employ longitudinal designs and large samples, and should consider the theoretical basis for the study expectations more extensively.     

Four-stage process model of the core factors of burnout: the role of work stressors and work-related resources

The impact of work stressors and work-related resources on emotional exhaustion and depersonalization, as the two core factors of burnout, is investigated. According to the German Action Regulation Theory work stressors are conceptualized as regulation problems that lead to work stress in terms of additional effort (e.g. working longer hours), increased intensity of effort (e.g. working at a faster pace), and risky action (e.g. by neglecting safety rules). Consequently, an extended process model consisting of objective work stressors, work stress, emotional exhaustion and depersonalization is proposed. Nurses from three general hospitals (N=482) provided data for evaluating this model. Complete mediation of work stress and emotional exhaustion were analysed by hierarchical regression analysis. The overall model was tested by structural equation analysis in two steps; in the first step the basic model was analysed while in the second step the model was extended by autonomy as a work-related resource. The process model could be confirmed with respect to: (1) the mediating function of work stress and emotional exhaustion, and with regard to (2) the direct impact of autonomy as a work-related resource on work stressors but not on emotional exhaustion and depersonalization. Methodological considerations and implications for work design and burnout prevention are discussed.     

Cognitive model of patient aggression towards health care staff: The patient's perspective

Aggression towards health care staff has become the focus for research as well as for government intervention. Negative effects upon staff and organizations have been established, yet few detailed explanations are offered for this aggression, and none represents the patient's perspective. This paper presents a model from the patient's perspective that takes account of situational variables, while also focusing upon patient cognitions. It also considers physiological responses related to arousal that might underpin aggression in an anxiety-provoking situation. In a previous study the frequency with which aggression was preceded by some anxiety-provoking event and the extent to which assailants displayed diminished cognitive processing were established; these were incorporated into the model. Increased anxiety commonly experienced by patients can have a negative effect upon cognitive processing. Anxiety generates a hyper-vigilance for threatening stimuli, induces selective attentional bias for threat, and causes a narrowing of attention, thus reducing cues and information upon which to make accurate appraisals and attributions. With such impairments, patients may make negative rather than positive attributions regarding actions of staff, which are frequently anxiety provoking. Thus, patients perceive staff behaviour as threatening rather than benign, and in the absence of positive attributions it will invoke an aggressive response. What health care staff perceive as aggression may be seen by patients as a defence against perceived attack. Changes in policy that take this into account may reduce future aggressive incidents.     

Burnout in Greek teachers: Main findings and validity of the Maslach Burnout Inventory

The factorial structure of the Maslach Burnout Inventory (Maslach and Jackson 1986) was investigated in a sample of 220 Greek teachers and was found to be similar to that reported by Maslach and Jackson. A job satisfaction measure was employed for the investigation of the discriminant validity of the burnout measure. Correlations between job satisfaction and the three burnout dimensions were found to be low to moderate. It is suggested that the relationship and the degree of overlap between emotional exhaustion and job satisfaction require further examination. Greek teachers reported lower levels of burnout on the emotional exhaustion and depersonalization scales than teachers in other countries. Finally, younger teachers experienced more emotional exhaustion than older ones and primary education teachers experienced more personal accomplishment and less depersonalization than their counterparts in secondary education.     

The behaviour of police officers in conflict situations: how burnout and reduced dominance contribute to better outcomes

Dominance plays an important part in police-civilian interactions. However, burnout is associated with a reduction in dominance, and this might, paradoxically, lead to more effective outcomes in conflict situations. There is a lack of knowledge about the effects of burnout in professional practice, and this multi-method study was conducted to better understand these dynamics. It is unique in that it combined self-reported burnout with observed behaviour in interactions with civilians. In this study, the relationships between the imbalance between demands and rewards, occupational burnout and police officers’ behaviour in conflict situations (in terms of dominance and effectiveness) were examined. A questionnaire was used to assess job demands, rewards and burnout among 358 Dutch police officers. In addition, police officers’ interactions with civilians were observed over 122 days. The results of structural equation modelling analyses showed that the imbalance between job demands and rewards was predictive of burnout (emotional exhaustion and depersonalization). Burnout, in its turn, predicted a decrease in dominant behaviour in conflict situations and, consequently, more effective conflict outcomes. These findings show that reduced dominance associated with burnout could in fact have positive consequences for professional behaviour in conflict situations. The benefits of reduced dominance in these situations should be taken into account in the training of professionals.     

The relationship between burnout and risk-taking in workplace decision-making and decision-making style

This study aimed to investigate what decision-making styles might be exhibited by employees who experience burnout. Using a Work Risk Inventory (WRI), developed for this study, which included generic workplace scenarios, it was also explored whether such employees take relatively more risky decisions. Risk was conceptualised as the adoption of decisions that threaten one’s reputation at work, job performance and job security. The mediating effect of the likelihood and seriousness of the consequences of the worst that could happen in each given scenario on the relationships between dimensions of burnout and risk-taking was also tested. A total of 262 employees in various occupations completed an online survey, including measures on burnout, decision-making styles and the WRI. As predicted, dimensions of burnout – exhaustion, cynicism and professional inefficacy – correlated significantly with avoidant decision-making and negatively with rational decision-making. The seriousness of the consequences of the worst-case scenario occurring mediated the relationship between professional inefficacy and risk-taking. In the context of identifying mechanisms by which burnout leads to risky decision-making, the findings suggest that employees’ sense of professional inefficacy determines their risky decision-making. The contribution to theory and implications for practice are discussed.     

Self-control demands, cognitive control deficits, and burnout

Self-control involves inhibiting undesired behaviours and emotions, and it can be particularly relevant in the service sectors. Recent theoretical developments in cognitive and social psychology suggest that the demands on an individual of exercising self-control have an effect as a source of stress at work. In turn, burnout could be associated with being unable to meet those demands. It was expected that cognitive control deficits, as assessed by a questionnaire measure of self-reported failures in perception, memory, and action, would function as a vulnerability factor in the relationship between self-control demands and indicators of job strain. Data from 630 staff members of a German municipal administration revealed significant main effects of both self-control demands and cognitive control deficits on the burnout dimensions of emotional exhaustion and depersonalization. Both predictors were positively related to burnout. In addition, the results provided clear evidence of the vulnerability hypothesis of cognitive control deficits. By way of contrast, musculoskeletal complaints did not reflect similar main and interactive effects of self-control demands and cognitive control deficits. The requirements for self control in the service sector are expected to increase as the sector expands, and the practical implications for this are discussed.