Burnout and collegial support in state psychiatric hospital staff

BURNOUT AND COLLEGIAL SUPPORT IN STATE PSYCHIATRIC HOSPITAL STAFF

PATRICK W. CORRIGAN, E. PAUL HOLMES, AND DANIEL LUCHINS

University of Chicago, Pritzker School of Medicine

To determine the correlates of burnout, 47 employees of a state psychiatric hospital completed measures of burnout, collegial support, prolonged anxiety, physical health, and job attitude. Results showed that burnout was associated positively with anxiety, frequency of illness, and contrary job attitudes, and correlated negatively with level of satisfaction with the collegial support network. Partial correlations showed that satisfaction with support systems diminished the effects of burnout on frequency of illness and job attitudes. Tests for divergent validity showed that these findings were specific to burnout and not other measures of job satisfaction or fulfill- ment. The results suggest that facilitating staff satisfaction with colleagues may reduce burnout and some of its deleterious effects.

Staff members of state psychiatric hospitals, charged with the care of severely men- tally ill adults, frequently experience severe burnout because of their work with this population. Burned-out staff members are less likely to be effective on the job (Maslach, 1982); patient care probably suffers as a result. One might think that, given the role of line-level clinicians in the mental health system, work-related stress in state psychiatric hospitals frequently may be the focus of empirical research by mental health researchers. However, surprisingly little empirical study has been completed on the effects of staff burnout in this population. The impact of burnout may be surmised, however, by ex- amining its influence on other helping professions.

Research has shown burnout to be associated significantly with generalized anxiety, low self-esteem, and self-doubt in other populations (Browner et al., 1987; Mattingly, 1977). Prolonged burnout is associated with significant health problems (Hamburg, Elliott, & Parron, 1982; Kahn, Hein, House, Kasl, & McLean, 1981), which may lead to greater absenteeism (Carroll & White, 1982; Maslach, 1976; Maslach & Pines, 1977). Burnout also affects attitudes toward work. Mental health workers who experience job stress perceive greater barriers to implementing treatment innovations that improve patient care and thereby decrease burnout (Corrigan, Kwartarini, & Pramana, 1992). One of the goals of the paper is to examine the relationships between measures of burnout and tests that assess anxiety, recent physical health, and job attitudes specific to inpatient psychiatric staff.

Research on social support suggests one factor that may buffer mental health staff members from job stress. Social psychology research has shown that individuals with large and satisfactory support networks are better able to cope with everyday stressors (Sarason, Sarason, & Pierce, 1990). Extrapolating these findings to the psychiatric hospital, staff members with large and satisfactory collegial support may suffer burnout less frequently. Along this line, better work relations among mental health workers have been shown to correlate with greater job satisfaction (Golembiewski, 1982; Pines & Maslach, 1978). Moreover, burnout has been shown to be diminished in settings in which colleagues are viewed as friendly and management supportive (Golembiewski & Munzen- rider, 1988). Similarly, staff perception of peers as disinterested in program development

Correspondence should be addressed to Patrick W. Corrigan, University of Chicago, Center for Psychiatric Rehabilitation, 7230 Arbor Drive, Tinley Park, IL 60477.

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is related to greater job stress (Corrigan et al., 1992). Another goal of this study was to elucidate the relationships of collegial support with burnout and its consequences.

Burnout is a complex phenomenon. Maslach showed that burnout comprises three factors (Maslach, 1976, 1978, 1982). Two significantly inter-related factors directly reflect the construct itself: emotional exhaustion (feelings of being emotionally overextended) and depersonalization (an impersonal response style to patients). The third factor - personal accomplishment - is relatively independent of burnout and represents the feel- ing of competence and success that ensues in the absence of prolonged job stress (Maslach, 1982; Maslach & Jackson, 1986). The diversity of conceptualizations about burnout has contributed to confusion about the separateness of burnout per se from other closely related constructs, such as job satisfaction and personal accomplishment (Meier, 1984). Including personal accomplishment in a study of the impact of burnout and collegial support tests the discriminant validity and specificity of results (Campbell & Fiske, 1959; Van Tuinen & Ramanaiah, 1979). In particular, anxiety, physical health, and job attitudes are expected to be related to a combination of emotional exhaustion and depersonalization that represents burnout and to be relatively independent of personal accomplishment.

METHOD

Subjects All nursing and clinical staff members of the AM and PM shifts on the Extended

Care Units at Tinley Park Mental Health Center (TPMHC) were invited to participate in this study. TPMHC is a 355-bed psychiatric hospital, owned and operated by the State of Illinois and located in the southern suburbs of Chicago. Staff members on the Extended Care Units are exposed to significant stress because they work with treatment refractory, schizophrenic patients, a group that has been shown to cause burnout in staff members of another study (Pines & Maslach, 1978). Extended Care patients typically have a chronic history of severe mental illness with repeated admissions and few skills to sustain community life. Average length of stay for these patients typically exceeds 15 months.

Fifty-one staff members completed test batteries, of which 47 were usable. The usable group represented 82.5% of the AM and PM shifts on the Extended Care Units. The sample was 50% female with an average age of 45.2 years (SD = 8.6). Thirty percent of the sample was single, 51.3% was married, and 17.9% was widowed or separated. On average, the sample completed 15.7 years of education (SD = 2.7). Nursing staff (i.e., nurses, mental health technicians, and mental health specialists) comprised 60.0% of the sample, and clinical staff (i.e., social workers, activity therapists, psychiatrists, psychologists, and administrators) made up the remaining 40.0%. Staff reported that 52.5% worked AM shifts and 47.5% worked PM. The staff was 41.7% African- American, 33.3% Caucasian, 16.7% Latino, and 8.3% Asian.

Dependent Measures Informed subjects who agreed to participate in the study completed six pencil-and-

paper measures of burnout, collegial support, prolonged anxiety, physical health, and work-related attitudes. Because the regression analyses central to testing this study's hypotheses are influenced by differential test reliabilities, information about the internal consistency (reported as Cronbach's alpha unless otherwise noted) of each measure is summarized. Subjects also provided information about their age, marital status, ethnicity, level of education, and job history with the Illinois Department of Mental Health and with TPMHC.

Masluch's Burnout Inventory (MBI). The MBI is a 22-item self-report measure that has been used widely to assess burnout in other helping professions (Maslach & Jackson,

Factors That Influence Stafl Burnout 705

1986). Subjects rated the frequency with which they experienced job-related stressors on a 7-point Likert scale. Factor analysis of the MBI has uncovered three factors: emotional exhaustion (EE), depersonalization (DP), and personal accomplishment (PA). The internal consistency of the subtests that comprised the factors was .90 for EE, .79 for DP, and .71 for PA.

Modified Social Support Questionnaire (SSQ). Sarason, Levine, Basham, and Sarason (1983) developed the SSQ to measure an individual’s perceptions about size and satisfaction of his or her support network. When subjects completed this pencil- and-paper measure, they provided the initials of individuals who supported them in generic life problems that are described in seven test questions. Subjects also reported satisfaction with their network vis-a-vis each life problem on a 6-point Likert scale (6 = very satisfied). For purposes of this study, the seven stimulus questions were rewritten slightly to reflect staff members’ perceptions of collegial support at the work setting. Subjects also reported satisfaction on the same 6-point scale. Internal consistency for number and satisfaction scores of the standard SSQ was .94 and .97, respectively. Internal consistency scores for the modified version were determined in this study.

State Trait Anxiety Inventory (STAI), Trait Version. Subjects rated 20 statements about how they generally felt on a Likert scale on which 1 is “almost never” and 4 is “almost always” (Spielberger, 1983). Internal consistency of the overall STAI Trait score was .84.

Health History Questionnaire (HHQ). When subjects completed the HHQ, they checked on a list of common illnesses those they suffered the previous year (Miller Com- munications, 1980). Subjects also reported the number of: visits to their physician, lab tests, outpatient surgeries, inpatient days, and medication prescriptions related to their physical health during the past year. A factor analysis was completed on data from this sample to determine the manner in which items grouped. Internal consistency of these factors was calculated in this study.

Barriers to the Implementation of Behavior Therapy (BIBT). The BIBT comprises 18 statements about barriers to introducing behavioral innovations at the subject’s mental health setting, which are rated on a 6-point Likert scale of agreement (Corrigan et al., 1992). The sum of ratings yielded an overall score with high internal consistency (Cron- bach alpha = .85).

Needs Assessment Inventory (NAI). Another way to measure the effects of burnout on staff members’ professional life is to assess their perceptions of programmatic shortcomings. Subjects in this study were instructed to identify, from a list of 57 items, program-related problems that they believe describe the Extended Care Unit. This 57-item checklist was developed elsewhere specifically to describe inpatient programmatic needs (Corrigan et al., 1994); an overall score equaled the number of endorsed items (Cron- bach alpha = .79).

Data Analysis One purpose of this study was to determine the relationship between component

factors of burnout and measures of collegial support, prolonged anxiety, physical health, and job attitudes. EE and DP were expected to be highly correlated and, therefore, were combined into an overall burnout measure (EE + DP) to simplify additional analyses. Relationships between MBI indices and other staff variables were better understood when the level of burnout was described. To do this, MBI scores for the sample included in this study were compared to norms gathered on a much larger standardization group.

Subsequent relationships were examined using Pearson product-moment correlations. The correlation coefficients that described the relationship of EE + DP with anxiety, physical health, and job attitudes were compared to the coefficients of PA with anxiety,


physical health, and job attitudes using Fisher’s t-tests. Discriminant validity of burnout was supported when correlation coefficients were significantly larger for EE + DP than PA.

Collegial support was represented in this study as a correlate of burnout that mitigated the impact of stress on anxiety, health, and job attitudes. This assumption would be tentatively supported if the relationship between EE + DP and physical health, anxiety, and job attitudes significantly diminished after collegial support was partialled out. Partial correlations were determined to examine the effects of partialling out collegial support.

RESULTS

Pearson product-moment correlations were completed to determine the relationship among EE, DP, and PA scores. As expected, EE and DP were highly associated (r = .53, p < .001) and, therefore, were summed to yield an overall burnout score, EE + DP. PA was not correlated significantly with the other two MBI factors (p > .05) and was analyzed separately. MBI factor scores for this study’s sample and for a mental health standardization group (Maslach & Jackson, 1981) are summarized in Table 1 for EE + DP and PA; difference between samples was nonsignificant @ > .50). Using the author’s nomenclature, the TPMHC sample scored in the average range of experienced burnout. Additional analyses showed that 30.2% of the sample scored in the high range of both EE and DP; 63.0% scored in the high range of PA.

Table 1 Means and Standard Deviations of MBI Scores for TPMHC Sample and for Madach and Jackson’s (1981) Standardization Group

MBI TPMHC Standardization index sample sample

Emotional Exhaustion 15.53 16.89 (11.79) (8.90)

Depersonalization

Personal Accomplishment

5.51 (4.96)

35.09 (8.58)

5.72 (4.62)

30.87 (6.37)

Note. -Standard deviations are included parenthetically. The standardization sample (N = 730) included psychologists, psychotherapists, counselors, mental hospital staff, and psychiatrists.

Between-group ANOVAs were completed to determine whether EE + DP and PA varied by staff member’s job classification, gender, and minority status. Results showed no significant difference in EE + DP across gender, F(1,40) = 3.18, but female staff members reported significantly greater PA. The group of African-American, Latino, and Asian staff members reported significantly greater EE + DP than the nonminority group, F(l,30) = 4.28, p < .05; significant differences in PA were not found by minority status, F(1,30) = .19. No significant differences in EE + DP were found between nursing and clinical staff, F(1,37) = . lo, but the clinical staff reported significantly greater PA, F(1,37) = 4.95, p < .05. Results of Pearson product-moment correlations found EE + DP to be correlated significantly with age (r = - .40, p < .OI) and number of years working in mental health (r = - .41, p -c .Ol) , but not education (r = .08). Con- versely, PA was correlated significantly with education (r = .40, p < .Ol), but not age (r = -.17) or job tenure (r = -.13).

Factors That Influence Stag Burnout 707

Internal Consistency of the HHQ and the Modified SSQ

Results of a factor analysis of seven variables from the HHQ yielded two mean- ingful factors with eigenvalues greater than 1 .O after a varimax rotation: Frequency of Illness (the number of illnesses the person experiences) and Frequency of Care (the number of procedures individuals seek for themselves). The Cronbach alpha of scale scores that represented the sum of items that comprise these factors was .62 and .65, respectively. The internal consistency for the Modified SSQ was .80 for number and .78 for satisfaction.

Internal consistencies for measures of burnout, social support, trait anxiety, physical health, programmatic needs, and barriers to behavior therapy ranged from .62 (HHQ Frequency of Illness) to .90 (MBI EE), a relatively narrow band. Although findings from the regression analyses need to be interpreted cautiously, they are not likely to be con- founded by tests varying in terms of reliability.

Relationship of Burnout with Collegial Support, Anxiety, Physical Health, and Job A ttitudes

Pearson product-moment correlations of EE + DP and PA with collegial support and other variables are summarized in Table 2. Results showed that EE + DP was correlated significantly with Trait Anxiety, Frequency of Illnesses, Perceptions of Program- matic Needs, and Perceived Barriers to Behavior Therapy. When a more conservative, Bonferroni criterion for interpreting the correlations' was used, three out of four of these correlation coefficients were significant. In terms of collegial support, EE + DP was related significantly to satisfaction, but not to size of the support network.

Table 2 Pearson Product-moment Correlations of MBI Burnout and Personal Accomplishment with Collegial Support, Physical Health, Trait Anxiety, Treatment Needs, and Perception of Barriers to Behavior Therapy

MBI factors EE + DP PA

STAI Trait Anxiety .e** - .32" HHQ Frequency of Illness .,,,* . O l a HHQ Frequency of Care - .06 - . I7

NAI Overall Perceived Programmatic Needs .,,** - .12" BIBT Overall Barriers to Innovations .39* - .01"

SSQ Size of Support Network - .I0 .I4 SSQ Satisfaction with Support Network - .40** .14=

"Correlation coefficients with MBI Burnout are significantly different (p < .05) from coefficients with Personal Accomplishment according to a Fisher's t-test. EE = Emotional Exhaustion; DP = Depersonaliza- tion; PA = Personal Accomplishment; MBI = Maslach Burnout Inventory; STAI = State Trait Anxiety Inventory; HHQ = Health History Questionnaire; NAI = Needs Assessment Inventory; BIBT = Barriers to the Implementation of Behavior Therapy; SSQ = Social Support Questionnaire.

*p < .Of. **p < .01. ***p < .001. Underlined coefficients meet Bonferroni criterion for significance.

'According to a Bonferroni adjustment, alpha = Bonferroni Significance Level = .05 = .008 -

N of correlations 7

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Contrast this pattern to the correlation coefficients with PA, where no significant associations were found. Results of Fisher’s t-tests showed that four of the seven pairs of correlation coefficients in the Table were significantly different. These findings support the discriminant validity of burnout (EE + DP) vs. personal accomplishment.

Partialling out collegial support. Partial correlations were determined between EE + DP and the four variables with which it yielded significant correlations - Frequency of Illness, Prolonged Anxiety, Overall Programmatic Needs, and Overall Barriers to Treatment Innovation- after removing variance attributed to Collegial Satisfaction. These relationships are summarized in Table 3. Results showed that the correlation between EE + D P and Frequency of Illness decreased from .42 to .30 after partialling out satisfaction. Similarly, the correlation between EE + DP and Overall Barriers to Treatment Innovation decreased from .42 to .33. Note, however, that partialling out collegial support had no effect on the relationship between burnout and measures of anxiety or perceived barriers to implementing treatment innovations.

Table 3 Pearson Product-moment Correlations and Partial Correlations (with SSQ Satisfaction Partialled Out) of E E i D P with HHQ Illness Frequency, STAI Trait Anxiety, NAI Treatment Needs, and BIBT Perception of Barriers to Behavior Therapy

Dependent variable Pearson product-moment Partial correlation by

correlation social support ~~~

HHQ Frequency of Illness .42 NAI Perceived Programmatic Needs .42

BIBT Perceived Barriers to Innovations .39 STAI Trait Anxiety .60

~

.30

.33

.39

.60

DISCUSSION

As found in other human service professions, mental health personnel who work in state hospitals may experience significant burnout. Burnout seems to have a variety of deleterious effects on its victims. Burnout in this study was correlated significantly with anxiety and with physical health. Burned-out staff members were more likely to experience prolonged anxiety and had frequent illnesses. Interestingly, greater frequency of illness did not correspond with more frequent visits to health care professionals. Burnout also was associated with negative job attitudes. Burned-out staff identified more shortcomings in the existing treatment program. They also thought there were greater barriers to implementing treatment innovations that might remedy these shortcomings.

Burnout also was found to be related to the staff members’ satisfaction with support from colleagues, but relatively unrelated to the size of the support system. Line-level clinicians who perceived peers as interested and supportive experienced less burnout. This effect is prominent regardless of whether the network comprises several, or just a few, peers. Future research should investigate whether the status of the staff member identified as support affects the relationship with burnout. Staff members who report influential administrators as helpful may experience less burnout than those who report their support as arising from line-level clinicians alone.

The relationships among collegial satisfaction, burnout, and measures of physical health, job attitudes, and anxiety were explored further in several partial correlations. Results suggest that collegial satisfaction mildly reduced the relationship between burnout and variables the represent frequency of illness and perceived programmatic needs.

Factors That Influence StaH Burnout 709

These differences were muted, however, and perhaps were limited by the power of the statistic and the size of the sample.

Unfortunately, correlational findings do not indicate clearly the directionality of relationships. Although we might infer that burnout causes more frequent illness, negative job attitudes, and prolonged anxiety, causality probably could occur in the opposite direction. Perhaps staff members who are sickly burn out more frequently. Negative work attitudes may expose the individual to burnout. Prolonged anxiety may be neither an antecedent nor a consequence of burnout; it may be an alternative definition. Finally, these analyses do not suggest clearly whether collegial support mitigates the deleterious effects of burnout or whether these are associated with another extraneous variable not included in this design. More rigorous path analyses that require much larger numbers of staff members would better address directionality issues.

Findings from this study seemed to support the specificity of the relationships between burnout and measures of physical health, anxiety, job attitudes, and collegial support. The combination of two interrelated MBI factors that comprise burnout (emotional exhaustion and depersonalization) was related significantly to the other variables, while personal accomplishment was not. This discriminant pattern suggests that the significant relationships may be attributed to burnout itself, rather than vague perceptions about job satisfaction.

Interestingly, patterns of burnout did not differ across job groups. Nursing and clinical staff were equally likely to be overwhelmed by burnout. This finding is somewhat surprising even though it concurs with other research (Corrigan, 1993). One would ex- pect psychiatric technicians and nurses to experience greater burnout because they work directly with patients almost the whole day on the relatively less structured ward. However, other studies found that social workers, psychologists, and psychiatrists who comprise the ranks of clinical staff are more likely to be disillusioned by patient care over time (Pines & Maslach, 1978).

Other demographic variables were found to correlate with burnout, which may ex- plain these findings. Age and work tenure (both indicators of experience) were correlated negatively with burnout. More difficult to interpret was the finding that minority staff members tended to be more burned out than their peers. This finding may suggest that minority personnel are more disaffected from colleagues as a whole. Results, however, contradicted this conclusion and showed that minority staff members had significantly greater satisfaction with collegial support, t(26) = 4.11, p < .001. The relationships between demographic variables and burnout need to be outlined further in future research.

The relationship between burnout and a satisfactory collegial network, if supported in additional research, suggests an important focus for staff development and stress management strategies. Decreasing burnout may have a secondary effect on patient care. As staff members feel less emotionally exhausted and depersonalized, relationships with patients may improve, and attitudes that foster productive treatment development may increase. Burnout can be decreased by facilitating satisfactory relationships among peers. Future research should investigate the effects of team building strategies on collegial support and burnout (Dyer, 1977).

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Burnout and collegial support in state psychiatric hospital staff