Burnout in radiation oncologists and oncology registrars in the Free State province

 1 School of Medicine, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa

2 Department of Oncology, University of the Free State, Universitas Annexe, Bloemfontein, South Africa

3 Department of Biostatistics, Faculty of Health Sciences, University of the Free State, Bloemfontein, South Africa

 

Correspondence: Dr Alicia Sherriff, Department of Oncology, University of the Free State, Universitas Annexe, Private Bag X20660, Bloemfontein, 9300, South Africa. e-mail: maliciasherriff@vodamail.co.za

 

ABSTRACT

Background: Stress and burnout are realities in many professions and the medical field of oncology is no exception.

Objectives: The study aimed to calculate the prevalence of burnout in radiation oncologists and oncology registrars in the private and public health sectors in the Free State. The use of stress management techniques was also investigated.

Methods: A cross-sectional study included all active, registered radiation oncologists and oncology registrars in the public and private sectors in the Free State. Participants completed an anonymous questionnaire which included the Maslach Burnout Inventory (MBI), consisting of the three subscales: depersonalisation, emotional exhaustion, and personal
accomplishment.

Results: Of the 22 questionnaires distributed, 20 were returned (90.9% response rate). Nineteen participants completed the MBI section. One participant (5.3%) had scores indicative of a high degree of burnout, no participants had moderate burnout, and six participants (31.6%) had scores indicative of low burnout. From the subscales scores, there was mainly evidence of depersonalisation (38.6%), followed by emotional exhaustion (26.3%). On average, the participants each used 12 functional and two dysfunctional stress management techniques. Participants with mainly low levels on the subscales (i.e. lower burnout) utilised, on average, twice as many functional techniques than those with mainly high levels on the subscales (i.e. higher burnout, 14 versus 7).

Conclusion: Although only one participant was classified as having a high degree of burnout, there was a risk for depersonalisation. This, in itself, is detrimental to patient care and professional fulfilment. With the high patient burden experienced by oncologists, techniques of stress management need to accommodate limited time and should not negatively impact on the daily routine.

 

Keywords: emotional exhaustion, depersonalisation, personal accomplishment, mismatch, stress management techniques

INTRODUCTION

Maslach et al. define burnout as ‘a syndrome of emotional exhaustion, depersonalisation and reduced personal accomplishment that can occur among individuals who work with people in some capacity.’1 They further state that stress is not necessarily determined by individual factors but by the person’s situations and circumstances.2 It is more difficult to address these situations and circumstances than individual factors, since individuals may be unable to change their working environments.3

The Maslach’s Burnout Inventory (MBI)1 is an internationally recognised and standardised model to assess the level of burnout.4 It consists of three subscales: emotional exhaustion, depersonalisation and personal accomplishment. Emotional exhaustion results in individuals being unable to give more of themselves on a psychological level. Depersonalisation is a cynical attitude and callousness towards the person to whom they are attending, which can result in the perception that the person deserves the challenges he or she is facing. A diminished level of personal accomplishment can lead to individuals feeling unhappy and dissatisfied with themselves and/or their working conditions.

The use of different measuring instruments and interpretations of Maslach et al.’s definition of burnout complicate comparisons between studies. A study in the United States reported that 61.7% of oncologists were burnt out (based on self-compiled questions about signs of burnout), while 83.2% felt that their colleagues showed signs of burnout.5 Kuerer et al.6 reported that 28% of members of the Society of Surgical Oncology experienced burnout (defined as high levels of emotional exhaustion or depersonalisation). More recently, it was reported that more than 70% of young oncologists in Europe showed signs of burnout.7

A handful of studies has been conducted on stress in medical professionals in South Africa. Thomas and Valli8 found high levels of occupational stress in 50 doctors at a public hospital, and a study of junior doctors at the Red Cross War Memorial Children’s Hospital9 found that all participants were on the high level of at least one of MBI.2 A third study10 found that 24.7% of medical professionals, including doctors and nurses, working in the field of oncology had high stress levels recorded on the depersonalisation subscale, 25.7% had high levels on the emotional exhaustion subscale, and 32.9% had high levels on the personal accomplishment subscale.

Oncologists in South Africa, like other healthcare professionals, have high patient loads, which might be a contributory factor to stress levels.

Table 1 shows the burden of doctors at the public health facility included in this study.  

The aim of the study was to calculate the prevalence of burnout in radiation oncologists and oncology registrars in the private and public health sectors in the Free State. The use of stress management techniques by the study participants was also investigated.

 

METHODS

This was a cross-sectional study conducted in 2014, and included all active, registered radiation oncologists and oncology registrars in the private and public health sectors in the Free State. Doctors not practising primarily in the Free State were excluded, as were those specialising in more than one field and currently practising in a non-oncology field. Thirteen radiation oncologists and nine oncology registrars were identified as potential participants, from the one public and two private hospitals that have practising oncologists in the Free State province.

 

Data collection

Data were collected by means of an English self-administered questionnaire which was divided into three sections.

Section A: Data were obtained for gender and details regarding the working environment. Three options were provided to assess the presence of a ‘hardy personality’, based on three personality characteristics or traits, viz. control, engagement and challenge.11

Section B: For this study, Maslach Burnout Inventory – Human Services Survey (MBI-HSS) was used.4 The MBI-HSS comprises three subscales, viz. emotional exhaustion, depersonalisation and personal accomplishment. Each subscale consists of a number of statements. The participant rates each statement, using a 7-point Likert scale, from 0 (never) to 6 (every day). The numeric total for each subscale classifies the level of burnout in that subscale as ‘low’, ‘moderate’, or ‘high’.1

Section C: This section determined the participants’ stress management techniques and six possible areas of mismatch between participants and their working environments, as defined by Maslach et al.2

• Workload: individuals unable to meet their work demands are more inclined to experience burnout.

• Control: refers to an individual’s feelings of control over sufficient resources to do the work; for example, lack of control over required resources, or insufficient authority to carry out the work in a manner they feel would be most effective, causes stress.

• Reward: individuals who feel that the reward, such as a salary increase or recognition, does not justify the working environment, have a tendency towards burnout.

• Community: this entails the connection between individuals and their colleagues; a good relationship between colleagues reduces the likelihood of burnout.

• Fairness: unfair treatment, such as inequity of workload, improper handling of salaries and promotions, and unfair dispute resolution, can worsen burnout.

• Values: burnout can occur when individuals have to set aside their own values and standards to perform their duties.

A category for dysfunctional stress management techniques12 was included to capture information regarding techniques that seemingly help in handling stress but, in reality, contribute to stress. To prevent participants from avoiding these options due to the negative term ‘dysfunctional’, these techniques were categorised as ‘alternative approach’ on the questionnaire.

The questionnaires were distributed to participants by hand at the respective departments/practices. The completed questionnaires, sealed in envelopes, were collected by the researchers.

 

Pilot study

A pilot study was undertaken with the help of five non-oncology medical practitioners: two medical practitioners in private practice, two in the public sector, and one registrar in the public sector. Section B, the MBI-HSS, was not tested during the pilot study as it is a standardised and internationally recognised inventory and may not be changed without permission. Feedback from the participants was evaluated and, consequently, sections A and C of the questionnaire were amended to include more comprehensive instructions for the completion of each.

 

Data management and analysis

A person was categorised as having a hardy personality if all three options (control, engagement and challenge) were selected by the participant.11

High level of burnout is indicated by a score of ≥ 27 for the emotional exhaustion subscale of the MBI, a score of ≥ 10 for the depersonalisation subscale, and a score of ≤ 33 for the personal accomplishment subscale1 (Table 2).

The combinations of the levels of burnout on each subscale are used to determine the extent of overall burnout: high levels of burnout on all three subscales are considered as a high degree of burnout, moderate levels of burnout on all three subscales are considered as moderate-degree burnout, and low levels of burnout on all three subscales are considered as low-degree burnout.4

Data were analysed by the Department of Biostatistics, Faculty of Health Sciences, University of the Free State, using SAS Version 9.3. Results were summarised by frequencies and percentages.

 

Ethical considerations

The study protocol [STUD NR 08/2014] was approved by the Ethics Committee of the Faculty of Health Sciences, University of the Free State. Permission was obtained from the Clinical Heads of the participating hospitals to conduct the study.

 

RESULTS

Twenty of the 22 potential study participants returned the questionnaires (90.9% response rate). One of the 20 did not complete the MBI-HSS section (section B). The majority of the participants were female (65.0%) and 12 (60.0%) were radiation oncologists (Table 3).

Most participants (n = 13, 65.0%) worked, on average, 41-54 hours per week, while half (50.0%) spent a further 6-10 hours on administration. Seven (35.0%) participants, mostly registrars, spent more than 11 hours per week on academic work or continuing professional development. The majority (n = 14, 70.0%) took 20-29 days annual leave.

Eight (40.0%) participants had a hardy personality. One (5%) participant selected two of the three characteristics, nine (45.0%) participants selected only one characteristic and two participants chose none of the characteristics.

 

Burnout

With regard to the MBI subscales, the highest percentage of participants scored on the high level for depersonalisation (38.6%), followed by emotional exhaustion (26.3%) (Figure 1).

Of the 19 participants who completed the MBI, one (5.3%) scored high on all three burnout subscales, and thus had a high overall degree of burnout. No participants had a moderate-degree of burnout and six participants (31.6%) had a low-degree of burnout. The remaining 12 did not fall into the high, moderate or low burnout categories as defined by the MBI guidelines,1 but scored various combinations of low, moderate and high for the different subscales.

Of the 19 participants, six (31.6%) had mainly high levels in the burnout subscales (high levels in all three subscales, or high levels in two subscales and moderate level in the third subscale). Four (21.1%) had mainly moderate levels (moderate levels in two subscales, and high or low levels in the third subscale), and nine (47.4%) had mainly low levels (low levels in all three subscales, or low levels in two subscales and moderate level in the third subscale).

Of the 13 female participants (61.5% of whom were consultants), most had high levels on the emotional exhaustion or depersonalisation subscales, while of the six male participants (50.0% of whom were consultants), most had high levels on the depersonalisation subscale (Table 4).

None of the eight participants with hardy personalities scored high on any of the subscales, compared to six of the other               

12 participants who scored high on at least two of the subscales.

The results for each subscale (N = 19) were compared with those from a normative sample of 1 104 doctors as per MBI-guidelines1 (Table 5).

Compared to the normative sample, the radiation oncologists and oncology registrars showed, on average, slightly lower levels of emotional exhaustion. The study participants’ mean perception of personal accomplishment was slightly higher, while the mean degree of depersonalisation was similar. None of the differences was significant, however.

 

Mismatch in the working environment

Mismatch occurred mainly in the control area (n = 13), followed by workload (n = 11), and fairness and reward (n = 7 in each area). A high workload (workload area) and unavailability of needed resources (control area) were selected most frequently (n = 10 each). Six participants indicated that they lacked authority to pursue work in the way the participant deemed most effective (control area), and five mentioned the unfair resolution of disputes (fairness area). In the reward area, four participants each indicated that they did not think patients appreciated the effort they put into their jobs, and that colleagues did not notice their achievements.

Only four participants indicated mismatch regarding community (colleagues) and only two indicated mismatch regarding values.

Factors where less than 15% of the participants report a mismatch were considered a ‘match’. These include reflection of insincere emotions (n = 1), dissatisfaction with current salary and benefits (no participants), no positive connection with colleagues (no participants), disregard of own value system (n = 2), and perception of unfair financial compensation (no participants).

 

As shown in Table 6, stress management techniques used by at least 80% of the participants included assertiveness when required (80.0%), focusing on the positive things in life (85.0%), accepting that one cannot change all the circumstances (90.0%), and focusing on the positive side of negative situations in the workplace (95.0%). All techniques listed in the acceptance approach were used by at least 55% of the participants. Lesser-used techniques were relaxation (20.0%) and avoiding perfectionism (30.0%). ‘Other’ responses included reading, listening to music, leaving the workplace at no later than 18:30, and avoiding working at home after 20:00.

On average, the participants each used 12 functional and two dysfunctional stress management techniques. Participants with mainly low levels on the subscales (low levels on at least two subscales) utilised, on average, twice as many functional techniques compared to participants with mainly high levels on the subscales (high levels on at least two subscales, 14 versus 7). The latter group utilised, on average, three dysfunctional techniques compared to the former which utilised one dysfunctional technique.

 

DISCUSSION

Burnout

Only one participant experienced burnout as defined by the MBI, but almost a third showed high levels of burnout on at least two of the three MBI subscales. The subscale high level findings are similar to results from a study conducted in Pretoria on health professionals in an oncology setting,10 regarding emotional exhaustion (Free State province study: 26.3%, compared to Pretoria study: 25.7%), but a higher percentage of our participants scored on the high level for depersonalisation (36.8%) compared to those in the earlier study (24.7%). High levels of personal accomplishment were much less common in our study (10.5% compared to 32.9%).10 Our participants scored similarly to the normative sample of the MBI-HSS on the three subscales.

The highest percentage of high level burnout on a subscale was for depersonalisation, which might be used as a coping mechanism. This might result in radiation oncologists and oncology registrars distancing themselves from their patients, leading to insensitive and negligent behaviour.

Due to the small sample size, subgroup analyses should be viewed with caution. More women than men had high levels of emotional exhaustion. This was also found in a study performed in medical officers and registrars at public healthcare facilities in Bloemfontein, South Africa. Sirsawy et al,13 postulated that this could be due to challenges facing female doctors, such as greater family responsibilities than their male counterparts.

Individuals with ‘hardy personalities’ experienced lower levels of burnout. This supports reports that hardy personality traits might protect the individual against stress and burnout.11,14,15 Persons with hardy personalities tend to handle stressful situations more effectively than less-hardy individuals.14 They also show less psychological strain when experiencing stress,15 and are inclined to have lower levels of burnout.11 However, our results also suggest that the absence of these traits do not necessarily correlate with high levels of burnout.

 

Mismatch between participants and their working environment

There was most mismatch in the areas of workload and control. This was not unexpected, given the high patient load in South African health institutions, particularly public health institutions. It is encouraging that the least mismatch was in the areas of community and values, which thus clearly reflects positive aspects within the work environment. The challenge is to maintain the low percentage of mismatch as these factors can compensate for areas that will be difficult to change.

 

Stress management techniques

Stress is experienced in many professions and the medical field of oncology is no exception. Identifying and applying the correct stress management techniques are vital to ensure that healthcare professionals can continue their work. A positive finding was the high percentage of participants using various functional stress management techniques. Stress management techniques used less frequently included techniques that could be time-consuming, such as relaxation, establishing social support and regular exercise.

Despite the small sample size, an inverse association between the number of functional stress management techniques and the level of burnout was found, suggesting that using these techniques might contribute to preventing or reducing burnout. This protective effect seems to be directly proportional to the number of techniques used. Similarly, participants with high levels of burnout used more dysfunctional and fewer functional stress management techniques compared to participants with moderate to low levels of burnout. It is therefore important to educate health professionals regarding which stress management techniques are functional and which are dysfunctional.

After the data were analysed, a comprehensive document on stress management techniques was distributed to the participants. The information collated in the document was provided by two psychiatrists and a registered occupational therapist working with burnout patients; information included in the document was also obtained by the researchers from two accredited websites, MindTools16 and Helpguide.17

 

Study limitations

• Despite the anonymous nature of the questionnaire, participants may still have been hesitant to complete the questionnaire honestly out of concern that they will be seen as incompetent.

• The study population included all radiation oncologists and oncology registrars in the Free State. However, the study population is too small to represent the field of oncology in South Africa, and sub-analyses of this small group are problematic.

 

Recommendations

To combat the effects of stress and therefore lower the levels of burnout, the researchers recommend equipping healthcare professionals with functional stress management techniques. At the management level, work load and resources which showed the most mismatch between participants and their working environment should be addressed.

 

For further research, the authors recommend the following:

• Enlarge the study to include more areas and participants

• Investigate the associations between the different stress management techniques and burnout

• Determine whether burnout in other medical specialty fields is also countered by these stress management techniques

 

CONCLUSION

The high ratio of patients to doctors in the oncology sector in the Free State led to this study. Even though the prevalence of full burnout based on the MBI definition might be low, the high patient burden leads to a great risk for depersonalisation. This in itself is detrimental to patient care and professional fulfilment.

With this high patient burden, time is a limiting factor. There is a need to develop and support stress management techniques that accommodate limited time and do not negatively impact further on daily routines.

 

LESSONS LEARNED

1. Radiation oncologists and oncology registrars working in both the private and public healthcare sectors are prone to high levels of depersonalisation. Female participants might be more prone to emotional exhaustion

2. Stress management techniques that are used less frequently might be those that are more time-consuming, such as relaxation techniques, establishing social support and regular exercise

 

ACKNOWLEDGEMENTS

We thank Mr J le Roux and Dr L van Zyl, clinical psychologists at the Free State Psychiatric Complex, Bloemfontein, as well as Ms E Meyer, occupational therapist at Elsabé Meyer Occupational Therapists and Optima Psychiatric Hospital, for their support with the compilation of the questionnaire and the action plan to counter burnout; Dr U Sirsawy, Universitas Hospital, Bloemfontein who allowed us to use an example of the Maslach’s Burnout Inventory as an addendum to our protocol; and Ms T Mulder, medical editor, School of Medicine, University of the Free State, for technical and editorial preparation of the manuscript.

 

DECLARATION

The authors declare no conflicts of interest or affiliations to commercial organisations.

 

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