Burnout syndrome and health risk

Introduction

The issue of BO has been of interest to researchers since the 80s of the last century, the original emphasis on the psychological and emotional impact of BO on a person is transferred to the area of monitoring the impact of BO on health, work performance and economic impacts not only with regard to helping professions, but the relationship between person and workload in general. BO syndrome is a gradually developing syndrome caused by prolonged stress at work. Persistent work stress leads to absences from work and probably causes deterioration of health in the sense of somatic illness.

From the plethora of Czechoslovak researchers dealing with BO from a psychological point of view, Kebza and Šolcová (1998, 2008) presented the issue most comprehensively and clearly in their works.

Among our authors, e.g. Buchancová and spol. We consider the fact that professional stress, professional burnout syndrome, heart attacks and myocardial infarctions as occupational accidents have become interesting as an object of serious research, but especially in connection with possible financial compensation (Buchancová et spol., 2001).

The mechanism of the effect of burnout syndrome on the state of health is explained in 3 ways: 1. research confirms that BO affects physiological functions that can turn into physical disease, at least increase the risk of disease (e.g. cardiovascular risk (Melamed et al. 1992, 2006 and i). 2. BO creates problems in social relationships through damage to mental performance and capacity to perform, which can affect both mental and physical health; 3. BO causes deterioration of lifestyle, especially increased alcohol consumption and smoking, which increases further morbidity (Schaufeli et al.1998).

In several studies, BO was associated with impaired mental health and etiologically different from depression (Schaufeli et al. 2001). More than two decades later, Ad Appels' vital exhaustion syndrome appears to be a supporting and appropriate concept, already in 1988 he pointed out the importance of chronic fatigue and vital exhaustion in relation to AMI, later to BO (1988, 1991, 1998).

Work load and occupational accidents

Work load, absenteeism and subsequent morbidity due to burnout were monitored by a team of Finnish researchers in 3895 workers, (paradoxically) in the wood industry. An increased score in the MBI questionnaire predicted absences from work due to health problems - both mental and physical. These were mainly cardiovascular, respiratory and musculoskeletal diseases. Regarding the separate components of burnout measured by the MBI, emotional exhaustion (EE) was associated with cardiovascular morbidity and nonspecific physical and mental symptoms. Cynicism was linked to disorders, problems of the digestive system. In their conclusions, the authors emphasize the importance of preventing burnout syndrome in terms of absenteeism, economic impact on work career and health care (Toppinen-Tanner et al., 2005).

Workload and CVD

Väänänen and co-workers followed the cardiovascular risk in a set of 7663 employees of the forestry industry in the private sector in Finland who had no positive history of CVD during 18 years (between 1986 and 2004). Low possibility to predict, or loss of predictability at work increased the risk of acute myocardial infarction (AMI), the risk was significant especially among employees aged 45-54. (Väänänen et al., 2008).

The components of the control of the working environment were focused on the ability to make decisions, use one's skills, and the ability to foresee. According to the authors, low predictability at work is an important component of work control, it increases tension and stress, and in the long term also the risk of developing AIM, especially among middle-aged employees (Väänänen et al., 2008).

Physiological differences between BO and healthy

Physiological differences between BO and healthy people were observed by Dutch researchers from the University of Amsterdam (De Vente et al., 2003). They compared the severity of BO in terms of work efficiency and in terms of health status. They monitored chronic fatigue syndrome and the presence of post-traumatic stress disorder (PTSD).

They compared individuals diagnosed with burnout syndrome and healthy individuals (there were 22 BO + 23 healthy individuals in the set). They monitored systolic and diastolic blood pressure (S/DTK), pulse rate (PF), and salivary cortisol (SC) during a model exercise consisting of mental arithmetic (MA) and public speaking. The physiological response of the organism was monitored in terms of the regulation of the stress response to sympathetic-adreno-medullary reactivity (SAM) and - hypothalamic-pituitary-adrenal reactivity (HPA). In their cohort, individuals diagnosed with BO had higher resting PF values. SC was increased within 1 hour after waking; BP at rest was without differences. 1. Physiological reactivity of SAM and HPA is impaired in individuals with BO. 2. Increased pulse rate and higher morning cortisol levels indicate persistent activity in individuals with BO; 3. The load is presented in the physiological response of the organism (De Vente et al., 2003).

Based on the study of BO syndrome, the research team around Melamed et al. distinguish the stages of burnout syndrome: 1. "Tense burnout" - sympathetic/sympathetic overtraining 2. "Listless burnout" - parasympathetic overtraining (Melamed et al., 1999). This division also has its measurable, physiological correlates.

Zanstra et al. monitored the physiological reactivity of individuals with BO and healthy individuals. In their study, subjects with BO had to exert a higher effort than healthy subjects for the same performance. After the procedure, there was no physiological balance in individuals with BO. Healthy and BO subjects differed in sympathetic-vagal reactivity (Zanstra et al., 2006).

Workload, BO and Cortisol

Another line of study of the effect of stress on BO, focusing on the possibilities of exact and objective verification of workload and physiological response, provides the measurement of cortisol values. Cortisol is the main glucocorticoid in humans. Basal values ​​have a characteristic daily rhythm, it is endogenously controlled. Excretion takes place in several secretory episodes during the day. The pulse amplitude is the highest in the morning hours, it has a high intraindividual stability in the rhythm. An increased amount of cortisol is formed under the influence of stressful stimuli during daily activities (Vigaš 1985; Vigaš, Ježová 1996, Vízi 2002).

I will mention some of the interesting studies dealing with this issue: Stressed teachers had higher cortisol levels especially in the morning; women had higher values ​​in the morning, men in the afternoon. Anger has been implicated in increasing the level of the hormone (Steptoe et al., 2000,2004). Morning cortisol levels had an effect on adrenaline excretion in scavengers (Slutier et al., 2000). Cortisol secretion in police officers was more dependent on the anticipation of a stressful situation than on its actual course (Piercecchi-Marti et al., 1999).

In the case of chamber orchestra musicians, despite the subjectively felt tension, no increased values ​​were recorded during the concert (Ježová et al., 1992).

The increased physiological response to workload in nurses has been confirmed in several studies: blood pressure and cortisol values ​​- were increased even after leaving the workplace. According to the authors, the body's increased physiological response to stress can be the reason for the increased risk of health damage in demanding occupations (Fox et al., 1993, Parker et al., 1995). No differences in urinary cortisol were detected in nurses during the working day, married women had higher levels overall during the night and during the day (Goldstein et al., 1999). Absences due to health discomfort in nurses due to loss of personal performance, emotional exhaustion were more linked to absences due to mental discomfort in nurses. Emotional exhaustion predicted a longer hospital stay (Parker et al., 1995).

Stress among surgeons was related to anxieties related to interference in personal life, excessive/unnecessary administration and the number of clients in the clinic (Green et al., 1990). Salivary cortisol in surgeons was higher during the workday compared to the weekend. Work experience had no effect on the endocrine response (Ježová et al., 1992). BO is manifested by an increased level of activation of the body and thus an increased level of cortisol secretion during the day. Studies comparing the body's endocrine response in BO and depression, on the other hand, are not unambiguous and consistent. Individuals with depression showed higher levels of cortisol than with BO (Kebza, Šolcová 2008.)

Research part

The author, although he was not a member of the research team, nor the researcher of the grant research task, participated in the engagement of experimental subjects - medical professionals, young surgeons at the heart surgery clinic (at the time of the research - SÚSCH) and nurses at the intensive care unit at DKC in 2002. There were 11 doctors - men and 19 nurses - women in the group of 30 health professionals. According to the basic data, it is clear that it is an inconsistent, non-standard file. The basic characteristics of the file are in table no. 1:

Methods

The analysis of circadian levels of salivary cortisol during an expected demanding working day and during rest was supposed to help verify the workload of a group of health professionals. Volunteers - experimental subjects gave 3 saliva samples for analysis during a demanding working day (7:00 a.m., 4:00 p.m. and 6:00 p.m.) and also during a day off - here it was specifically Saturday. The protocol was compiled by prof. Hedgehog and salivary cortisol were analyzed in the ÚEE SAS laboratory as part of their research tasks).

Questionnaires were used on a set of volunteers to measure lifestyle (compiled by the author); screening questionnaire for measuring quality of life QL WHO/EURO 98; Maschalchová questionnaire for measuring BO MBI – 22 item version used doc. Kebzom in the international study of SZU Prague; from the questionnaire for measuring hostility by R.Williams - DHW; scale for assessing A type of behavior (guided interview and modification of the Bortner scale), the level of experienced stress was measured by a self-assessment scale developed by the author.

Fig. 1 Levels of salivary cortisol in nurses measured during work and during time off at the intervals: 7.00, 16.00 and 18.00h; (n=19). Cortisol levels were significantly higher at the workplace than at home, specifically in the morning, *** p<0.001.

Results from a comparison of salivary cortisol levels in nurses and doctors-surgeons during a demanding working day and during rest were used from the materials of another work (Vízi, 2002).

Fig. 2 Levels of salivary cortisol in surgeons measured during work and during time off at 7:00, 16:00 and 18:00; (n=11). Results represent means ± SEM; no significant differences were found in the cortisol level in the monitored conditions.

Salivary cortisol in young surgeons did not differentiate between working days and days off (Vízi 2002).

Results

Values obtained in the MBI questionnaire are in tab. no. 2:

In the top row of the table, the indices represent the threshold values for individual subscales of the MBI. On the scales of emotional exhaustion and depersonalization or cynicism (both frequency and intensity), both groups had diagnostically elevated values ​​indicative of BO; in the personal performance scale, the values ​​were not indicative of BO. High scores of cynicism indicating hostility syndrome were also confirmed in both groups in the DHW questionnaire by R. Williams, they are shown in table no. 3.

Doctors were more cynical and aggressive than nurses, nurses showed higher values of anger. Total values ​​of hostility in women were higher than in men, in both groups Williams' hostility syndrome was significantly higher than e.g. in patients after CABG (Selko et al., 2007).

Quality of life according to QLWHO: almost 60% of the probands were in the range indicative of impaired QL, 30% of them had values ​​requiring professional intervention. From the point of view of the assessment of ATS, the representation of ATS in the file was up to 90%. The methodological "dis/advantage" was that the author had the opportunity to observe the behavior and reactions of the study participants at work and outside the experiment over a longer period of time. In terms of subjectively experienced stress, inconsistent data were obtained, which confirmed that, in addition to work stress, they perceive problems in their personal and partner lives very intensively, economic and social factors were significant in terms of their subjective assessment.

In the qualitative analysis of subjectively felt problems among nurses, I will list some: Appreciation and satisfaction at work: calm and appreciated 37%; partially appreciated 53%, not appreciated 10%; Time spent at the workplace – 12.5 hours. Reflections on changing jobs 37% had decided/considered changing jobs, 63% had not; Feelings after work: tiredness and exhaustion - 63%, finally it's over - 27%, relief and satisfaction were experienced by only 10% of respondents. Only 22% of nurses had time/conditions for regenerating strength after work, 58% had time and conditions sometimes, 20% stated that they did not have conditions. Movement and exercise as part of regeneration and a healthy lifestyle: only 10% exercised regularly; 48% sometimes exercised; 42% did not engage in physical activity; significantly more women smoked - 42.5% than men - 25%.

Discussion

The set of subjects, although methodologically unbalanced and inhomogeneous, represents a "representative" sample of specialized medical facilities in Bratislava and Slovakia. They were young, ambitious, healthy, professionally successful individuals. The tension and dissatisfaction discussed in the corridors, the strained work and interpersonal relationships that were not paid attention to, were verified both on a physiological and psychological level.

The different values ​​of salivary cortisol during the workload and during the time off from work were disappointing for the solvers of the physiologically oriented grant and diploma task, in the context of the obtained psychological profiles and the knowledge of the work color of both workplaces, they were interpretable in accordance with the knowledge of foreign studies. In the monitored period, both workplaces underwent serious organizational changes that affected both doctors and nurses. Organization of the work of surgeons, or intensive care physicians were excluded from the possibility of truly relaxing during their time off work (the need to be on the phone despite not being on duty, the need to go to the workplace during personal time off, these were young people who had serious problems in their personal lives, or were under constant work and non-work stress). Nurses, mostly after the end of their working hours, were able to devote themselves to leisure and personal activities more effectively than male doctors.

High values ​​of hostility could raise doubts about the validity of the techniques used. The author is of the opinion that in BO it is hostility more significantly than emotional exhaustion that increases the risk of somatic failure, but also of risky behavior of the affected person. A nurse and a doctor have different work organization and work competencies: the nature of the nurse's work in the ICU did not allow leaving the room as variable as the doctor's. Paradoxically, despite the high values ​​indicative of burnout syndrome, these were high-performing health workers in an attractive position capable of performing well. The results provided a (deformed) current picture of the Slovak health worker: able to perform, but emotionally exhausted, cynical, angry and even angry, hostile. These emotional characteristics can lead to damage to the entrusted patient, his iatropathogenesis, but also to the deterioration of interpersonal relationships and damage to the health of specific medical professionals.

There was partial agreement and discrepancy between the subjective assessment of the current state, physiological reactivity and the results of the psychological examination and the subjective assessment of the health and behavior of the monitored persons. Healthcare professionals are often misled about their knowledge of stress. They underestimate the warning signals sent by the cardiovascular system in particular, indicating an increased level of stress for insufficient regeneration. Due to the pre-feminization of health care, the need for a differentiated view of gender differences in the response to burden and stress comes to the fore. The cardiovascular and physiological response of the female and male organism to stress is different: women react with an increased resting pulse rate, loss of menses, men with an increase in BP, especially DTP, and a decrease in libido.

The mechanism of the effect of the burnout syndrome on the state of health as stated in the introduction of this work: activation of physiological functions that can turn into a physical disease, at least increase the risk of the disease, e.g. cardiovascular risk (Melamed et al. 1992, 2006 and i), impairment of mental performance and capacity to perform, which creates problems in social relationships and can affect both mental and physical health; deterioration of lifestyle, especially increased alcohol consumption and smoking, thereby increasing further morbidity (Schaufeli et al.1998) requires further investigation. Despite the time gap, it appears to be a current and supporting concept of vital exhaustion syndrome (Appels et al. 1988, 91, 98).

Studies comparing the body's endocrine response in BO and depression are not unambiguous and consistent. Individuals with depression showed higher levels of cortisol than with BO (Kebza, Šolcová, 2008). The author of this work has a rather reserved attitude towards these conclusions. The dynamic interaction of a person with the environment, physiological, neuroendocrine and mental processes can also result in different results in the time continuum than the actual experimentally obtained values. BO can represent an intermediate stage in the long-term continuum, which may or may not result in either an emotional, mental or somatic disorder.

About the importance of improving the so-called there is no doubt about the management and organizational skills of health professionals in stress management and prevention of BO. Education and social psychological training and stress management training are important/necessary. Due to the riskiness of the work of health workers, psychosocial determinants must be taken into account to the same extent as for the general population. Health workers, like other employees, despite their education and position, are not immune to the effects of workload. Significantly reduced quality of life, and the accumulation of behavioral and physiological indicators requiring intervention indicate that, also/especially in top workplaces, it is necessary to devote more attention to occupational risk monitoring and BO prevention. Also based on the presented findings, DKC started educating nurses on the prevention of BO. It was stress management training and communication skills training. Without the initiative and support of senior staff, any behavioral intervention among health professionals will not be successful.

Conclusions

BO syndrome is a gradually developing syndrome caused by prolonged stress at work. Persistent work stress leads to absences from work and probably causes deterioration of health in the sense of somatic illness.

Despite the increase in information about burnout syndrome, in practice the issue is not given enough attention. Based on more recent studies, it is clear that BO is not the domain of health and helping professions. Work stress in itself, but also the expectation of the burden, has a negative impact on the emotional, endocrine, somatic, behavioral and psychosocial areas of the individual. The risk of somatic failure due to BO is a reality.

The techniques of clinical psychophysiology and health psychology can be both quantitative and qualitative workload monitoring. Subjective vs. objective load assessment may not always be consistent. The author indicated the methodological, ethical and organizational pitfalls of such a "humane experiment". The high representation of individuals with BO requiring/suitable for intervention is alarming, especially responsible leaders and organizational workers should pay attention to this. The motivation of health professionals to actively cooperate remains questionable. The reserves in the "management" of workplaces are insufficiently used, both by executives and by the disabled themselves.

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Addendum The presented work published in this form was not part of any research project or grant. The author assisted the research team in recruiting subjects. The graphs used are published with the permission of the supervisor - the author of the diploma and research thesis.

The contribution was published in the proceedings of the conference ,,Psychology of health - Health and wisdom. Health psychology and burnout syndrome. Gender differences in health". The conference was held in 2009. Editor: Dr. Dušan Selko, CSc., MPH, Mgr. Róbert Ďurka, PhD. Proceedings published with the financial contribution of Národného ústavu srdcových a cievnych chorôb, a. s., Bratislava Publisher: National Institute of Heart and Vascular Diseases, a. s., Bratislava in the Publishing House MAURO Slovakia s.r.o., Bratislava 2010, ISBN 978-80-968092-6-4