Burnout syndrome in physiotherapists working in the Podkarpackie province in Poland

1 Introduction

The term burnout syndrome was introduced by the American psychiatrist Herbert Fraudenberg in 1974. Almost simultaneously and independently from Fraudenberg, burnout syndrome was described by a social psychologist Christina Maslach in social workers, psychiatric nurses and lawyers who complained of negative perceptions and disappearance of empathy and feelings towards their patients or clients in the workplace. Further papers on the issue of burnout syndrome have shown that this phenomenon occurs more frequently than previously thought [1].

There are many definitions that attempt to interpret the phenomenon of burnout. Currently, burnout is most often referred to as a syndrome of characteristic mental and somatic symptoms which are the result of chronic stress most often associated with work. The most vulnerable occupational groups are physicians, nurses, physiotherapists, and others who work in close relationships involving a high degree of responsibility [2–5].

According to Maslach theory [6], the term burnout is associated with such concepts as emotional and psychophysical exhaustion, depersonalization, and a reduced sense of professional accomplishment which comprise the multifaceted model of burnout. Emotional exhaustion is associated with somatic symptoms such as headaches, drowsiness, and irritability. Depersonalization is manifested by routine, instrumental treatment of another person. Lowering of the sense of professional accomplishment leads to perception of oneself as incompetent, lacking in skills or the ability to succeed. Often, a person experiencing burnout does not notice these disturbing symptoms, or finds them trivial and consequently the problem intensifies and becomes chronic. The negative emotions related to burnout syndrome are also transferred to other areas of life, which can cause disturbed relationships outside of work [7].

An analysis of the prevalence of burnout syndrome and its causes among health professionals is a topic increasingly explored by researchers. However, there are only a few publications on this subject among physiotherapists who are in direct contact with the patients that were unable to fully meet expectations of a complete return to fitness. A lack of opportunities for self-decision-making on patient rehabilitation, workload, low social prestige, and ultimately low earnings are stressors that may lead to the appearance of burnout symptoms among Polish physiotherapists [8]. This seems to be particularly important in regard to executive regulations in the Physiotherapist Act which came into force in May 2016 that address issues of vocational training, professional responsibility and post-graduate education. Perhaps it would be advisable to introduce preventive measures in the form of teaching employees how to deal with stressful and difficult work situations. It may also be worthwhile to create educational programs on stress management at the stage of physiotherapy vocational training [9].

The aim of this study was to assess the prevalence of burnout syndrome among physiotherapists and determinants related to sex, age, education, workplace, occupational activity, work experience and financial situation.

2 Material and methods

Eighty six professionally active full time physiotherapists from Łańcut city and district participated in the study (Łańcut – population 18.000, Łańcut district – 1 urban municipality and 6 rural communes, urbanization rate – 23.3%) and Przeworsk city and district (population: 15.500; Przeworsk district: 3 urban municipality and 8 rural communes, urbanization rate – 26.7%).

3 Method

A Polish version of the Maslach Burnout Inventory (MBI) [10], adapted and verified by Pasikowski, was used to measure burnout. The inventory contains 22 test questions and responses to individual items are organized in a scale from 0 (the respondent never experienced the sensation) to 6 (the respondent experiences these feelings every day). According to the accepted methodology, the following general scales assigned to each questionnaire and the maximum score were assessed:

Emotional Exhaustion (EE): questions 1–3, 6, 8, 13, 14, 16, 20 — max 54 points,

The higher the scores in the general scales of EE and DP, the higher the level of burnout, in PA the lower the result, the higher the burnout rate [10, 11].

4 Results

There were 65 women (75.6%) and 21 (24.4%) men in the study group. The age of the subjects ranged from 22 to 53 ( x ¯ = 30.1). The subjects were divided into three age groups: 21-30 yrs (53 subjects – 61.6%), 31-40 years (24 subjects – 27.9%) and over 41 years (9 subjects – 10.5%).

The most numerous group was holders of a Bachelor’s degree – 52 people (60.5%), followed by Master’s degree holders – 23 people (26.7%) of which 5 were specialists in physiotherapy (5.8%) and 6 technicians (7%). The average work experience in this profession was 6.9 years, ranging from 1 year to 30 years. Dividing work experience into categories, we found 52 people (60.5%) with experience from 1–5 years, 25 people (29%) worked from 6 to 15 years and 9 people (10.5%) worked 16 years or more. The highest number of people worked in an outpatient rehabilitation center – 36 (41.9%), 21 (24.4%) had a private practice, 20 (23.2%) worked in a hospital ward, 5 (5.8%) worked in a pediatric rehabilitation center, and 4 (4.7%) in nursing homes. Twenty-six people (30.2%) dealt with kinesitherapy, while 12 (14%) with physical therapy and 5 subjects (5.8%) with massage. The highest number of people – 43 (50%) performed, according to needs, all aforementioned physiotherapy procedures for their patients. Physiotherapists have defined their financial situation mostly as average – 52 (60.5%), 23 (26.7%) as good and 11 (12.8%) as poor.

In the examined group of physiotherapists, we observed a low level of EE ( x ¯ = 15.99), low DP level ( x ¯ = 4.31), while PA was moderate but approaching high ( x ¯ = 31.63).

No significant relationship between age and burnout was observed. At the same time, the average level of EE was the highest in the group over 40 years of age ( x ¯ = 21.33). The lowest level of DP occurs in the group 21-30 year ( x ¯ = 3.43). The level of PA can be considered high in the age groups 21–30 ( x ¯ = 31.6) and 31–40 ( x ¯ = 31.2), respectively.

We observed that DP was significantly more common in men (p = 0.0159), and the result approaches moderate level. In women there is a low intensity of this domain of burnout. There are no significant relationships between burnout and sex in the remaining domains (Table 1).

There are significant relationships between education and burnout. EE and DP are highest among the masters with specialization and the lowest among technicians. The loss of sense of personal accomplishment is high in the masters (also with specialization), and it is moderate in the Bachelors and technicians (Table 2).

EE was the highest among physiotherapists working in nursing homes, while the smallest among those working at a pediatric rehabilitation center. Loss of PA was the lowest among physiotherapists working in outpatient rehabilitation clinics and those having private practice. Significant dependencies occur in the domain of DP, which in the highest intensity occurs in people working in hospital wards and the smallest among people working with children (Table 3). Additionally, there are no statistically significant differences in the parameters like level of education and work experience between these analyzed groups.

The highest EE – a moderate level was found among people with the longest work experience (above 16 years). Also, DP in this group was the greatest, but there are no statistically significant differences. In terms of PA, there are no significant differences (Table 5).

Among people whose financial situation is poor, the highest levels of EE, DP and loss of PA were found. However, only differences between groups in terms of EE were statistically significant (Table 6).

The analysis of the presented results of our research shows that Polish physiotherapists are not a group where burnout syndrome is a very big problem. Both emotional exhaustion and depersonalization are not closely related to the physiotherapist group, but low levels of personal accomplishment suggest the need for action for improvement. Decreased satisfaction with professional achievements is manifested by a decrease in the sense of one’s own competence and work efficiency. As a result, one may come up with a misconception about own unsuitability and resignation. This may be associated with depression and stress related to the profession. The sense of professional success is combined with support and mutual help among staff, improving professional skills, and with the ability to influence decisions made at work. In connection with the above, employers should care for shaping proper interpersonal relations in the workplace, ensuring that the individual can develop the necessary knowledge and skills as well as the ability to directly influence the work within the scope of competence [1]. Literature analysis shows that the scale of burnout may vary from country to country. Similar levels of burnout to Polish physiotherapists have been found in their Norwegian and Spanish colleagues. Research has shown that only 4% of physiotherapists in Spain are characterized by high levels of burnout [12, 13]. Similar studies in Cyprus showed that the level of burnout in physiotherapists varies from low to moderate [14]. According to S. Ogiwara and Hayashi, Japanese physiotherapists are characterized by moderate burnout [15]. Studies in Italy have shown that this occupational group experiences more frequent burnout symptoms than nurses [16]. Another Italian study pointed to the high risk of burnout in a group of physiotherapists, speech therapists and occupational therapists [17]. The above differences may be dictated by different cultural, religious or economic conditions, as well as by a different organization of work depending on the model of health care. However, they concern high numbers of physiotherapists in the world from low to high degree.

When analyzing individual dimensions of burnout in our own studies, we observed a moderate level approaching high loss of sense of personal accomplishment, especially in the age groups 21–30 and 31–40. No statistically significant differences were found in the incidence of burnout and age, which is consistent with other studies. However, the researchers agree that the level of professional burnout increases with age, especially in the area of emotional exhaustion [18, 20]. Our studies indicate a significantly higher incidence of depersonalization in men. Similar results were obtained by Pustułka– Piwnik et al. and Ozyur et al. [21, 22]. Regarding other dimensions, there was no relationship between sex and occupational burnout, but a number of studies show more frequent symptoms of burnout among women in the medical profession, especially in terms of emotional exhaustion and loss of personal accomplishment [19, 23]. There was a clear association between professional burnout and educational level. This relationship is significant in terms of emotional exhaustion and depersonalization. The loss of sense of personal accomplishment is also high among the masters and masters with specialization. Tragea et al. [24] found similar relationships investigating burnout among Greek physiotherapists. The cause of such a state of matters is probably inequitable relationships among the members of the therapeutic team, where often the physiotherapist, despite his higher education and many years of experience, and thus higher expectations, occupies a place of medium level medical staff. Also, difficult and responsible work with patients that is not supported by decent earnings can contribute to indifference to the needs of patients or loss of faith in one’s own skills and abilities.

There is also a significant association of the workplace with the occurrence of burnout syndrome, especially in the aspect of depersonalization, which is highly characteristic of people working in hospital departments. These results are consistent with studies conducted among physiotherapists in Poland [21] and in other European countries and outside Europe [25, 26]. Low levels of emotional exhaustion, lack of concern for the well-being of patients, or their instrumental treatment is observed in people working with children. Working with young patients is very difficult and demanding, but as often emphasized by pediatric physiotherapists, the effects of therapy can be really rewarding, which probably translates into low values in each of the three dimensions of burnout. Not everybody shares this point of view. There are studies that demonstrate that working with children is one of the causes of burnout syndrome [27, 14]. Perhaps the type of disorder most often treated by a physiotherapist working with children is important. However, the results are ambiguous.

Studies of Cypriot physiotherapists draw attention to the length of work experience as one of the reasons for the emergence of burnout syndrome in this occupational group [14]. Tragea et al. reported similar causes of burnout analyzing this phenomenon among physiotherapists in Greece [24]. Also, in this study, there was a significant relationship found between work experience and emotional exhaustion, largest for those who worked over 16 years as physiotherapists. However, alarming fact is that the particular dimensions of occupational burnout are already visible in physiotherapists working 5 years or less. According to our own research on physiotherapists who have identified their financial situation as poor, there is a significant difference in the level of emotional exhaustion and they also achieved the highest results in other dimensions. These data do not differ from other studies that focus on financial aspects as a cause of stress leading to burnout syndrome. Low income often requires additional employment, which results in undue workload. In addition, it entails less opportunities for rest, mental and physical regeneration, hobbies or social gatherings, which is very important in preventing burnout. There are many studies that clearly show that too many work hours, a large number of “difficult” patients and high employer demands are very strong predictors of burnout syndrome [28, 29].

This study shows that among Polish physiotherapists, burnout syndrome is not very serious, which does not rule out the risk of burnout symptoms. Importantly, this study allows identification of certain relationships that may predispose a physiotherapist to burnout. Therefore, it is important to take some action to prevent this kind of burnout. These could be in the form of stress management training, relaxation classes, a focus on improving interpersonal skills, or taking good care of the workplace and proper relationships between employees. Employers should clearly state what they expect of an employee, promote culture of work, and encourage leisure [30]. Taking up such activities can benefit not only the “burnout physiotherapist” but also patients, employers and families.

Conflict of interest

None to report.