Comparative analysis of the burnout syndrome index between contract and freelance physiotherapists: An observational study

Abstract

BACKGROUND:

Burnout syndrome has been extensively studied in different health science professions. It has been less studied in physiotherapy than in professions such as medicine. Moreover, it is not known how the working condition influences this syndrome.

OBJECTIVE:

The main objective of this study was to compare the burnout index between contract and freelance physiotherapists in the private sector in the Community of Madrid, Spain.

METHODS:

A cross-sectional study was performed with 174 participants divided into 2 groups; one group was composed of contract physiotherapists (n = 87) and the other group was composed of freelance physiotherapists (n = 87). A Mann–Whitney U test was performed for comparison between the groups. Spearman’s correlation coefficient was used to analyze the correlations between the burnout syndrome index and the secondary variables.

RESULTS:

There were statistically significant differences when comparing the groups, with a large effect size for the burnout index with a higher rate among contract physiotherapists (78 [71–84.75]) than in freelance physiotherapists (61.5 [55–72.75]).There were also significant differences in the type of patients treated, number of patients treated per day, time spent per patient, and the annual salary range between the contract and freelance physiotherapists.

CONCLUSION:

Contract physiotherapists who participated in this study had a significantly higher burnout syndrome index than freelance physiotherapists. Other socio-occupational variables were also found to be related to the burnout syndrome index in freelance physiotherapists and contract physiotherapists. The results of this study could be of interest for new occupational health strategies to reduce the burnout index in contract physiotherapists.

Keywords

Physiotherapy psychosocial aspects salary workloads healthcare quality

1 Introduction

Burnout syndrome has been studied by numerous authors and was first defined in 1974 by Herbert Freudenberger as feelings of failure and exhaustion resulting from overload due to demands on workers’ energy, personal resources, and spiritual strength. In 1981, Maslach and Jackson provided a definition from a 3-dimensional perspective, introducing emotional exhaustion, depersonalization, and feelings of low achievement or personal and/or professional accomplishment [1 –4]. Although there is no single accepted definition for burnout syndrome, there appears to be consensus in that it involves a response to chronic work stress, a subjective experience that encompasses emotions and attitudes, with harmful implications for the individual and the organization and, in general, is mainly produced within the occupational framework of professions that focus on delivering public services and care [3, 5].

The available evidence indicates that there are 4 stages of burnout syndrome based on the disease’s progression [6]. The mild stage is characterized by nonspecific physical symptoms such as headaches and back pain. During the moderate stage, insomnia, attention deficit, and concentration problems occur. During the severe stage, absenteeism increases, as does work aversion and alcohol/psychoactive drug abuse. Lastly, the extreme stage produces isolation, chronic depression, existential crises, and suicide risk [6].

Numerous studies have shown that the causes of the syndrome are related to the ways in which work is organized, which can be classified into 9 categories: 1) job characteristics; 2) work volume and tempo; 3) working hours; 4) participation and control; 5) professional outlook, status, and salary; 6) role in the organization; 7) interpersonal relationships; 8) institutional culture; and 9) balance between family and work life [3 , 7]. Studies have shown that physiotherapists who work more hours per week, along with those who feel they are underpaid and those who feel there are no opportunities for career growth, are at increased risk of burnout syndrome [8, 9].

This syndrome frequently affects healthcare practitioners due to the care provided for the patient’s emotional needs, which can contribute to the practitioner’s physical, emotional, and mental exhaustion [10]. It has been observed that the overall prevalence of burnout syndrome in healthcare practitioners in Spain is 4.5%. The practitioners who most experience this syndrome are nurses and nursing assistants, almost 38% of whom feel they lack personal accomplishment [11]. After nurses and nursing assistants come medical professionals, with a 12.1% rate of burnout syndrome. Lastly, there are dentists, psychologists, and nutritionists, whose rates do not reach 6% [12]. The literature on burnout syndrome in physiotherapy is growing. A recent study had shown that physiotherapists had a significant decrease in feelings of low performance and personal and/or professional achievement, more likely in those in which economic conditions were unfavorable [8]. In contrast, a previous study had shown that emotional exhaustion is the most frequent factor for burnout in physiotherapists [13]. Another study had found that the physiotherapists evaluated presented a moderate burnout index and that there was a correlation between the emotional exhaustion subscale and the efficacy or type of work, but they did not determine the type of work [14]. Although the evidence is growing, fewer studies have been conducted on this topic in physiotherapists compared with other health professions [3].

Regardless, we are unaware of any study that has compared physiotherapists’ burnout syndrome index based on working conditions, whether freelance or contracted. We therefore suspect that the personal accomplishment subscale could be the one most affected based on this condition and not so much the emotional exhaustion and depersonalization subscales.

Based on the above, the main objective of this study was to compare the burnout syndrome index among contract and freelance physiotherapists in the private sector of the Community of Madrid (Spain). The secondary objective was to observe whether there were differences in variables directly related to the work setting, such as the number of patients treated daily and the annual salary range.

2 Materials and methods

2.1 Study design

We conducted an observational, cross-sectional study with freelance and contract physiotherapists in the private sector who conduct their work activity in the Community of Madrid. The sample was collected between September 2019 and March 2020.

The study’s procedure was approved by the ethics committee of the La Salle University Center for Advanced Studies (CSEULS-PIA-040/2019). The study protocol followed the Strengthening the Reporting of Observational Studies in Epidemiology standards [15]. Similarly, the study’s procedure is in accordance with the Declaration of Helsinki. After giving their informed consent to participate in the study, the volunteers completed the survey, which complied with the necessary criteria for participant anonymization.

2.2 Participants

The sample consisted of 174 private-sector physiotherapists divided into 2 groups consisting of 87 freelance physiotherapists and 87 contract physiotherapists who conducted their professional activities in the Community of Madrid. The sample was recruited by non-probability purposive sampling.

The inclusion criteria were as follows: possessing a university degree in physical therapy; being employed as a physiotherapist in the healthcare setting at the time of the survey; working in the private sector; and working in the Community of Madrid.

We excluded from the study all those who conducted their professional activities in the public sector; who were on a leave of absence or on vacation; who did not properly understand Spanish; or who conducted their clinical activity outside the Community of Madrid.

2.3 Procedures

During the data collection, we complied with the criteria established for participant anonymization. The results were obtained by disseminating the Maslach Burnout Inventory-Human Services Survey, along with the questionnaire on socioeconomic variables, in social networks or by email. The responses were sent and classified automatically in an Excel spreadsheet designed to categorize the responses according to the replies. These responses were organized randomly and without any type of personal data that could identify the participant through the Microsoft forms platform.

2.4 Variables

The variables measured in this study were the burnout syndrome index and the participants’ demographic, societal, financial, and occupational variables.

2.4.1 Primary variable

2.4.1.1. Burnout syndrome index. The burnout syndrome index was assessed using the Maslach Burnout Inventory-Human Services Survey, a Likert-type, self-administered questionnaire on the feelings and attitudes of professionals at work [16]. The survey measures the rate and intensity at which individuals experience this syndrome and consists of 22 items divided into 3 subscales: emotional exhaustion, depersonalization, and personal accomplishment. An overall score of 1–33 points on the scale is considered low burnout, 34–66 points is considered moderate burnout, and 67–117 points is considered a high level of burnout. On the emotional exhaustion subscale, 0–18 points is considered low, 19–26 is considered moderate, and 27–54 is considered high. On the depersonalization subscale, 0–5 points is considered low, 6–9 is considered moderate, and 10–30 is considered high. On the personal accomplishment subscale, 0–33 points is considered low, 34–39 is considered moderate, and 40–56 is considered high (Maslach et al., 1997; Serrano Gisbert et al., 2008). The questionnaire has shown good reliability and validity, presenting an internal consistency with a Cronbach’s alpha coefficient of 0.88 [17].

2.4.2 Secondary variables

The study’s secondary variables were the demographic, social, financial, and occupational variables, which were measured by a survey that consisted of a series of questions in which the participants marked the option that best fit their current situation.

2.4.2.1. Age. The participants marked their corresponding age range, which was grouped as follows: 18–23 years; 24–29 years; 30–35 years; 36–41 years; 42–47 years; 48–53 years; 54–59 years; 60–65 years; and > 65 years.

2.4.2.2. Sex. The participants indicated their sex, with the options being male or female.

2.4.2.3. Marital status. The participants indicated which marital status option corresponded to their situation. The options were single; in a stable relationship; married; divorced; and widowed.

2.4.2.4. Workload. The participants indicated the condition that most resembled their work situation: 1–8 hours or 8–12 hours.

2.4.2.5. Types of patients. The participants indicated the condition that most resembled their work situation: insurance companies; private patients; or a combination of the two.

2.4.2.6. Number of patients treated daily. The participants indicated the number of patients they usually treated daily: 1–8; 9–16; 17–24; 25–32; 33–40; or > 41.

2.4.2.7. Time dedicated to each patient. The participants chose one of the following options to indicate the time allocated to each session:<10 min; 11–20 min; 21–30 min; 31–40 min; or 41–60 min.

2.4.2.8. Shift work. The participants indicated which shift they were on at the time of the survey, choosing one of the following options: morning shift; afternoon shift; or split shift.

2.4.2.9. Seniority. The participants indicated the number of months they had been in their current job.

2.4.2.10. Annual salary range. The participants indicated their salary based on the following options:<14,000 euros; 14,000–20,000 euros; or > 20,000 euros.

2.5 Sample size

We conducted a pilot study to determine the effect size between contract and freelance physiotherapists for the self-fulfillment subscale of the burnout syndrome index. The sample size was estimated with G*Power from the University of Dusseldorf, Germany, for Windows [18].

An independent sample Student’s t-test analysis was used to detect the mean difference between groups, given that the burnout syndrome index was the main factor of interest. The estimate was based on a pilot study with a sample of 15 participants per group. A medium effect size of 0.55 was used to obtain 95% statistical power (1-β error probability) with an α error level probability of 0.05, suggesting a sample size of 174 participants (87 per group).

2.6 Statistical analysis

The statistical software SPSS version 27.0 (SPSS 21 Inc., Chicago, IL, USA) was used to perform the analysis. A significance level of 5% (p-value<0.05) was set. The normality of the data distribution was assessed using the Kolmogorov–Smirnov test. Fisher’s exact test was used to analyze the categorical variables. The categorical variables are presented as n (%), and the continuous variables are expressed as mean±SD and/or median (first to third quartile).

Comparison of the burnout index between groups was performed using a Mann–Whitney U test, given that the data did not follow normal distribution. The association between the main variable and secondary variable was assessed using Spearman’s rank correlation coefficient. The value of this coefficient was interpreted as follows: little or no correlation (<0.30); moderate correlation (0.30–0.60); and high correlation > 0.60) [19].

3 Results

We received a total of 305 responses, of which 174 were valid, thus fulfilling the sample size calculation. Once the required 174 responses were correctly completed, the questionnaire was closed and no further responses were received (Figure 1). A total sample of 174 physiotherapists were recruited and divided into 2 balanced groups (87 contract physiotherapists; 87 freelance physiotherapists). We performed a hypothesis test of the demographic variables, such as sex; age, weight, and height ranges; and marital status (Table 1).

Fig. 1

Flow diagram of the procedure for the selection of valid responses.

Table 1

Descriptive statistics for demographic outcomes

Measures	Freelance physical therapists (n = 87)	Contracted physical therapists (n = 87)	P value; Fisher’s exact test
Age (%)			0.17
18–23	6 (6.9)	8 (9.2)
24–29	42 (48.3)	51 (58.7)
30–35	17 (19.6)	19 (21.9)
36–41	18 (20.7)	7 (8.0)
42–47	3 (3.4)	1 (1.1)
48–53	1 (1.1)	1 (1.1)
Gender (%)			0.45
Male	50 (57.4)	44 (50.6)
Female	37 (42.6)	43 (49.4)
Weight (%)			0.50
40–50	1 (1.1)	3 (3.4)
50–60	18 (20.7)	22 (25.3)
60–70	21 (24.2)	22 (25.3)
70–80	19 (21.9)	21 (24.2)
80–90	20 (23.0)	17 (19.6)
90–100	7 (8.0)	2 (2.2)
>100	1 (1.1)	0 (–)
Height (%)			0.34
150–160	4 (4.6)	10 (11.5)
160–170	29 (33.4)	31 (35.6)
170–180	28 (32.1)	29 (33.4)
180–190	22 (25.3)	14 (16.1)
190–200	4 (4.6)	3 (3.4)
Marital Status (%)			0.34
Single	23 (26.4)	24 (27.6)
Stable partner	44 (50.6)	48 (55.2)
Married	20 (23.0)	13 (14.9)
Divorced	0 (–)	2 (2.3)

Values presented in number (%); Weight in KG; Height in cm. *p < 0.05; **p < 0.001.

3.1 Main variable

The Mann–Whitney U test showed statistically significant differences in the intergroup comparison for the burnout index, with a higher rate among contract physiotherapists. (Figure 2). Similarly, contract physiotherapists performed significantly poorer on all 3 subscales. Table 2 shows the intergroup differences of the subscales for the burnout syndrome index.

Fig. 2

Differences in the burnout syndrome index between contrated physiotherapist and freelance physiotherapist.

Table 2

Descriptive and comparative analysis between groups for the burnout syndrome index

Measures	Freelance physical therapists (n = 87)	Contracted physical therapists (n = 87)
Emotional exhaustion subscale**	16[8–30.75]	33.5[26.25–41]
Depersonalisation subscale**	6[3–9.75]	13[9–16.75]
personal accomplishment subscale**	39.5[34–43]	31[26–39]

Values presented in median [interquartile range]. *p < 0.05; **p < 0.001.

3.2 Secondary variables

We performed a qualitative analysis of the following variables using Fisher’s exact test: workload, intervention setting, number of patients treated, time employed to treat patients, shift work, seniority, and salary range. Fisher’s exact test showed no statistically significant intergroup differences (p > 0.05) except for the patient type variables (F = 23.05; p < 0.001), indicating that most of the freelance physiotherapists treated patients privately. In contrast, most contract physiotherapists treated a combination of patients covered by insurance companies and patients paying out of pocket. There were significant differences in the number of patients treated in a day, with contract physiotherapists treating more patients (F = 24.70; p < 0.001). We also found significant differences in the time dedicated to each patient (F = 22.37; p < 0.001) and in the annual salary range (F = 11.86; p = 0.003), both of which were lower for the contract physiotherapists (Table 3).

Table 3
Descriptive and comparative analysis between groups for secondary variables

Measures Freelance physical therapists (n = 87) Contracted physical therapists (n = 87) P value

Workload 0.24

1–8 hours 58 (66.7) 66 (75.9)

8–12 hours 29 (33.3) 21 (24.1)

Type of patients <0.001

Insurance companies 1 (1.1) 9(10.3)

Privates 66 (75.9) 36 (42.0)

Privates+Insurance companies 20 (23.0) 42 (47.7)

Number of patients per day <0.001

1–8 55 (63.2) 28 (32.2)

8–16 21 (24.1) 26 (29.9)

16–24 5 (5.7) 8 (9.2)

24–32 4 (4.6) 9 (10.3)

32–40 2 (2.3) 6 (6.9)

>40 0 (–) 10 (11.5)

Time per patient <0.001**

<10 min 2 (2.3) 13 (14.9)

11–20 min 7 (8.0) 16 (18.4)

21–30 min 6 (6.9) 9 (10.3)

31–40 min 8 (9.2) 14 (16.1)

41–60 min 64 (73.6) 35 (40.3)

Shift work 0.40

Morning shift 17 (19.5) 19 (21.8)

Afternoon shift 14 (16.1) 20 (23.0)

Split shift 56 (64.4) 48 (55.2)

Seniority (months) 0.16

0–12 21 (24.2) 28 (32.2)

13–24 16 (18.5) 23 (26.4)

25–36 9 (10.3) 13 (14.9)

37–48 6 (6.9) 5 (5.7)

49–60 10 (11.5) 6 (6.9)

61–72 3 (3.4) 5 (5.7)

73–84 4 (4.6) 2 (2.3)

85–96 0 (–) 0 (–)

96–108 2 (2.3) 2 (2.3)

109–120 7 (8.0) 2 (2.3)

121–132 0 (–) 0 (–)

133–144 1 (1.1) 0 (–)

>145 6 (6.9) 1 (1.1)

>240 2 (2.3) 0 (–)

Annual salary range 0.003*

<14.000 euro 34 (39.1) 43 (49.4)

14.000–20.000 euro 32 (36.8) 39 (44.9)

>20,000 euro 21 (24.1) 5 (5.7)

Measures	Freelance physical therapists (n = 87)	Contracted physical therapists (n = 87)	P value
Workload			0.24
1–8 hours	58 (66.7)	66 (75.9)
8–12 hours	29 (33.3)	21 (24.1)
Type of patients			<0.001**
Insurance companies	1 (1.1)	9(10.3)
Privates	66 (75.9)	36 (42.0)
Privates+Insurance companies	20 (23.0)	42 (47.7)
Number of patients per day			<0.001**
1–8	55 (63.2)	28 (32.2)
8–16	21 (24.1)	26 (29.9)
16–24	5 (5.7)	8 (9.2)
24–32	4 (4.6)	9 (10.3)
32–40	2 (2.3)	6 (6.9)
>40	0 (–)	10 (11.5)
Time per patient			<0.001**
<10 min	2 (2.3)	13 (14.9)
11–20 min	7 (8.0)	16 (18.4)
21–30 min	6 (6.9)	9 (10.3)
31–40 min	8 (9.2)	14 (16.1)
41–60 min	64 (73.6)	35 (40.3)
Shift work			0.40
Morning shift	17 (19.5)	19 (21.8)
Afternoon shift	14 (16.1)	20 (23.0)
Split shift	56 (64.4)	48 (55.2)
Seniority (months)			0.16
0–12	21 (24.2)	28 (32.2)
13–24	16 (18.5)	23 (26.4)
25–36	9 (10.3)	13 (14.9)
37–48	6 (6.9)	5 (5.7)
49–60	10 (11.5)	6 (6.9)
61–72	3 (3.4)	5 (5.7)
73–84	4 (4.6)	2 (2.3)
85–96	0 (–)	0 (–)
96–108	2 (2.3)	2 (2.3)
109–120	7 (8.0)	2 (2.3)
121–132	0 (–)	0 (–)
133–144	1 (1.1)	0 (–)
>145	6 (6.9)	1 (1.1)
>240	2 (2.3)	0 (–)
Annual salary range			0.003*
<14.000 euro	34 (39.1)	43 (49.4)
14.000–20.000 euro	32 (36.8)	39 (44.9)
>20,000 euro	21 (24.1)	5 (5.7)

Values presented in number (%); Weight in KG; Height in cm. *p < 0.05; **p < 0.001.

3.3 Relationship between burnout syndrome index and work variables

A correlation analysis of the self-employed physiotherapists showed a moderate positive correlation between the emotional exhaustion subscale and the workload (rho = 0.332; p < 0.01) and between the burnout index and the workload (rho = 0.334; p < 0.01).

In contracted physiotherapists, there was a moderate negative correlation between the depersonalization subscale and the time spent with each patient (rho=–0.343; p < 0.01) and a moderate positive correlation between the personal accomplishment subscale and the time spent with each patient (rho = 0.326; p < 0.01) (Table 4).

Table 4
Correlation coefficient analysis for the relationship between burnout syndrome index and secondary variable in contracted physiotherapists (n = 87) and freelance physiotherapists (n = 87)

Age Workload Number of patients per day Types of patients Time per patient Shift work Seniority Annual salary range

Emotional exhaustion subscale Freelance physical therapists 0.137 0.332** 0.128 0.067 –0.081 0.023 0.035 –0.174

Contracted physical therapists –0.151 0.148 0.095 –0.046 –0.166 –0.045 –0.051 –0.99

Depersonalisation subscale Freelance physical therapists –0.093 0.154 0.275** 0.226* –0.241* –0.036 0.020 0.072

Contracted physical therapists 0.002 0.051 0.210* 0.009 –0.343** –0.260* 0.019 –0.061

Personal accomplishment subscale Freelance physical therapists 0.128 –0.129 –0.221* –0.066 0.150 0.012 0.102 0.166

Contracted physical therapists 0.022 0.016 –0.185 –0.124 0.326** 0.142 –0.040 0.046

Burnout syndrome index Freelance physical therapists 0.164 0.334** 0.105 0.093 –0.055 0.034 0.070 –0.091

Contracted physical therapists –0.164 0.210 0.108 –0.122 –0.124 –0.075 –0.114 –0.064

Age	Workload	Number of patients per day	Types of patients	Time per patient	Shift work	Seniority	Annual salary range
Emotional exhaustion subscale	Freelance physical therapists	0.137	0.332**	0.128	0.067	–0.081	0.023	0.035	–0.174
	Contracted physical therapists	–0.151	0.148	0.095	–0.046	–0.166	–0.045	–0.051	–0.99
Depersonalisation subscale	Freelance physical therapists	–0.093	0.154	0.275**	0.226*	–0.241*	–0.036	0.020	0.072
	Contracted physical therapists	0.002	0.051	0.210*	0.009	–0.343**	–0.260*	0.019	–0.061
Personal accomplishment subscale	Freelance physical therapists	0.128	–0.129	–0.221*	–0.066	0.150	0.012	0.102	0.166
	Contracted physical therapists	0.022	0.016	–0.185	–0.124	0.326**	0.142	–0.040	0.046
Burnout syndrome index	Freelance physical therapists	0.164	0.334**	0.105	0.093	–0.055	0.034	0.070	–0.091
	Contracted physical therapists	–0.164	0.210	0.108	–0.122	–0.124	–0.075	–0.114	–0.064

*p < 0.05; **p < 0.01.

4 Discussion

The results of this study demonstrated that the contract physiotherapists had a high level of burnout syndrome, higher than that of the freelance physiotherapists, who presented a moderate level of burnout syndrome. In our research, we observed significant differences between the groups, with higher indices on the emotional exhaustion and depersonalization subscales for the contract physiotherapists than for the freelance physiotherapists.

The burnout syndrome index has been studied in other health science professions, such as medicine and nursing. Studies of doctors and nurses have shown that the type of specialty and working conditions are key elements in the development of burnout [20 –24]. During the last few years, the assessment of burnout syndrome in physiotherapy has been growing, although there is a lack of evidence regarding the analysis of burnout syndrome among freelance and contracted physiotherapists, and it is difficult to analyze it according to specialty because they are not legally recognized. However, research has shown that physiotherapists who treat neurological and pediatric patients have higher scores on the personal accomplishment subscale and the emotional exhaustion subscale compared with physiotherapists who do not specialize in these fields [8, 25]. In terms of studies that analyze this syndrome in physiotherapists without specifying the specialty, it should be highlighted that the results of our study coincide with those reported in various studies performed in Spain in which the physiotherapists analyzed had a medium-high level of burnout syndrome [26, 27]. Along these same lines, a study conducted in Poland concluded that the risk of burnout syndrome among physiotherapists was high, with medium risk scores on the emotional exhaustion and self-realization subscales [28].

In terms of our study’s secondary variables, our results showed no statistically significant differences in the demographic variables. However, we did observe significant differences in the following variables: type of patient, number of patients treated per day, time dedicated to each patient, and salary range. Regarding the number of patients treated daily, the contract physiotherapists had more patients for shorter periods, which could be a risk factor for this syndrome due to the shorter time dedicated to each patient [28]. Managing the number of patients and the time devoted per session can have a greater effect on workers with weak coping strategies for job stress, who have the perception of little control over their situation, and who, in turn, are more likely to feel ineffective in their job, promoting low personal accomplishment, emotional exhaustion, and depersonalization [20, 29].

Along these lines, one research study had shown that = hysiotherapists who feel that they are not valued as economically as they deserve are at greater risk of suffering burnout syndrome [8]. Similarly, Bruschini et al. had shown that the physiotherapists analyzed in their study presented high rates of emotional exhaustion related to the fact of being in direct contact with the patient [9]. In addition, they found that the number of working hours per week and difficult working conditions were associated with an increased risk of burnout syndrome [9]. Similarly, another study had suggested that direct patient contact was the main antecedent of burnout syndrome [14]. This suggestion is interesting, because it could open up new lines of research in relation to patient experiences. In fact, a recent study of Spanish physiotherapists had shown that there was a relationship between burnout index and satisfaction with daily clinical practice, finding a direct association between a high burnout index and few years of clinical experience or little postgraduate training [30]. Furthermore, this same research group had demonstrated that the presence of high levels of depersonalization and emotional exhaustion was related to poorer emotional management and less empathy, directly affecting patient care [31].

Based on the above, further research is needed on the factors influencing burnout syndrome, but we suspect that there are also external determinants related to the environment of the burned out health professional that could affect their quality of care and their working conditions [4 , 33].

4.1 Limitations

This study has significant limitations that should be considered when interpreting the results. The most important limitation of the study is the presentation of a non-probability sample. Due to this type of sampling, our results should be taken with caution, and it does not ensure full representation of the studied population, given that only 2 possible physiotherapist working conditions have been analyzed; due to this, many responses did not meet the inclusion criteria. Also, given that it was a cross-sectional study, causal relationships could not be established.

4.2 Clinical implications

This study provides relevant information about physiotherapists that would be useful for companies to consider in order to establish occupational health policies. Based on the most significant results, the number of patients treated per hour and the low salary of the staff should be modified to reduce the risk of burnout syndrome among workers. These data could be used to demonstrate to insurance companies that physiotherapy sessions are poorly paid in Spain. In addition, the current policy could lead to a reduction in the quality of care and indirectly have repercussions on clinical characteristics that in the medium-to-long term could lead to higher costs for insurers, such as the chronicity of symptoms or the use of protocols that lose specificity.

A study performed in Shanghai concluded that it was necessary to improve rehabilitation services, suggesting an improvement in resources and improving the care provided by rehabilitation professionals, because it should be in everyone’s interest to improve the quality of life of people with disabilities [34].

5 Conclusion

The contract physiotherapists who participated in this study had significantly higher levels of burnout syndrome than the freelance physiotherapists, showing high levels of emotional exhaustion and feelings of depersonalization in their work. Moreover, we demonstrated that the contract physiotherapists had significantly more patients to treat daily, had a shorter time dedicated to each patient, had treated more insurance patients than private patients, and had a lower salary range. In contrast, no significant differences between groups were shown to exist for variables such as shift work, total number of daily work, or years of experience.

The results of this study should be taken with caution but should be studied by companies because they could lead to more beneficial occupational health policies.

Ethical approval

The study was conducted in accordance with the Declaration of Helsinki and approved by the Human Research Ethics Committee of the La Salle University Center for Advanced Studies (CSEULS-PIA-040/2019).

Informed consent

Informed consent was obtained from all subjects involved in the study.

Conflict of interest

The authors declare no conflict of interest.

Footnotes

Acknowledgments

The authors thank all participants for their collaboration and for allowing them to carry out this research for the knowledge of their profession.

Funding

This research received no external funding.

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