Burnout in nurses and physicians working at an oncology department

Psycho-OncologyPsycho-Oncology 18: 543–548 (2009)Published online 22 October 2008 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/pon.1432

Burnout in nurses and physicians working at an oncologydepartment

Ahmet Alacacioglu1�, Tugba Yavuzsen1, Meliha Dirioz2, Ilhan Oztop1 and Ugur Yilmaz1

1Institute of Oncology, Dokuz Eylul University, Izmir, Turkey2Dokuz Eylul University Hospital, Izmir, Turkey

Abstract

Purpose: Burnout is associated with decreased job performance and commitment, predicts

stress-related health problems, and low career satisfaction. The specific objectives in our study

were to assess the levels of burnout and to investigate the interrelationships between

demographic characteristics and burnout health-care professionals working with cancer

patients in Turkey.

Methods: A questionnaire-based study was conducted in 77 physicians and 56 nurses working

in an oncology clinic at the university hospital. We used quantitative survey to assess burnout

levels in participants as well as sociodemographic variables. Data were collected using a

Turkish version of the Maslach Burnout Inventory (MBI).

Results: Nurses had significantly higher scores of emotional exhaustion (EE) when compared

with the physicians, but no significant difference was found between two groups regarding other

burnout components. Significant correlations were found in three different components of the

MBI, as well as between each component, age and work experience in nurses and physicians.

There were statistical significant differences for each of MBI subscales according to age groups

in physicians. EE and depersonalization (D) were significantly higher in the p29 years of age

group than in the older age groups, while personal accomplishment (PA) score was significantly

lower in this age group. EE, D, PA were significantly higher in single physicians compared with

married physicians.

Conclusions: Low level of PA was relatively high among Turkish physicians and nurses

working in oncology department compared with previous studies. Younger and single

physicians had higher burnout levels compared with older and married ones.

Copyright r 2008 John Wiley & Sons Ltd.

Keywords: burnout; physicians; nurses; cancer; oncology

Introduction

Burnout is a term used by Freudenberger [1]. It wasdescribed as the state of tiredness, disappointment,and hopelessness in health workers [1]. Burnout is asyndrome that consists of depersonalization (D),emotional exhaustion (EE), and low personalaccomplishment (PA) leading to decreased effec-tiveness at work according to Maslach and Gold-berg [2,3]. They stated that EE results fromdecrease or loss of selfconfidence and interest inone’s profession as well as feelings of fatigue andweakness. In this case, individual feels him orherself as exhausted and stressed too much in hisprofessional life. D represents the interpersonalcontext dimension of burnout. PA describes thefeelings of productivity, adequacy, and copingsuccessfully [4].Burnout is associated with decreased job perfor-

mance and commitment, predicts stress-relatedhealth problems, and low career satisfaction. Abroad range of professions (including physicians,

nurses, and educators) can experience burnout [5].It is a type of prolonged response to chronic job-related stressors, and therefore, it has a specialsignificance in healthcare where staff experienceboth psychological and physical stress. There isalso an important cultural context for occupationalstress processes. Various social, political, andeconomic factors shape the health-care environ-ment, changes in public policy, cutbacks ingovernment funding, etc. [6].

Health-care staff working in an oncology clinic isunder the high risk of burnout and requires enoughenergy to confront all problems and self devotion.Burnout syndrome is also prevalent among medicaloncologist [7–9]. In 1991, Whippen et al. havereported that 56% of physicians met the criteria forburnout syndrome [9]. Moreover, this syndromemay cause symptoms that negatively affect qualityof life [10]. Offering care to cancer patients maygive rise to stress, dissatisfaction, alienation fromwork, and exhaustion in health professionals. Theprevalence of burnout and psychological distress

* Correspondence to:Institute of Oncology, DokuzEylul University, Balcova35340, Izmir, Turkey.E-mail: [email protected]

Received: 6 March 2008

Revised: 11 July 2008

Accepted: 12 July 2008

Copyright r 2008 John Wiley & Sons, Ltd.

among cancer-care physicians, nurses, and otherphysicians [7–11] has been reported by studies.According to these studies health workers mayexperience multiple stressors including a sense offailure or frustration when patient’s illness pro-gresses, feelings of powerlessness against illness andits associated losses, role conflicts and ambiguity,and the failure to enable a good death [8].The health-care system in Turkey has a highly

complex structure. It was provided by public,quasi-public, private, and philanthropic organiza-tions. The relationship between these institutions isnot well regulated. Health-care workers includingphysicians and nurses have many factors inducingburnout such as environmental factors [4,5,7,12,13]. These are unclearly job definition, low levelof working education, delay in the issuing of newnursing law, conditions of overtime work forcingone’s capacity, low wages, inadequacy of equip-ment and materials, too long working hours, andexcessive number of patients to give care. It mayalso be thought that lack of organizations in healthsector may influence the work life of health-careworkers adversely in Turkey.The specific objectives in our study were to assess

the levels of burnout and to investigate theinterrelationships between demographic character-istics and to compare the levels of burnout inphysicians and nurses working with cancer patientsin Turkey.

Patients and methods

A questionnaire-based study was conducted in 77physicians (medical oncologists, internists, and,radiation oncologists) and 56 nurses working in anoncology clinic at the university hospital. We usedto quantitative survey to assess burnout levels inparticipants as well as sociodemographic variables.

Data collection

All participants were given information about thestudy and agreed to participate in the research. Thequestionnaire consisted of two parts. In the firstpart, there were questions to determine demo-graphic features of the subjects and it wascompleted during face-to-face interviews by trainedinterviewers. In the second part, the MaslachBurnout Inventory (MBI) [14], a self-administeredquestionnaire, was used to measure burnout. It wastranslated into Turkish and its reliability wasrecalculated by Ergin [13].The MBI is a 22-item questionnaire that is

considered as the gold standard measuring tool forburnout (Appendix). It has three subscales: EE, D,and PA. EE consists of nine items measuringthe reduced energy, emotional, and cognitive

distancing from the job; D consists of five itemsmeasuring cynicism, lack of engagement, anddistancing from the patients, treatment of patientsas inanimate, unfeeling objects, and PA consists ofeight items measuring perception of having aninfluence on others, working well with others, anddealing well with problems [9]. Each item had a5-point rating scale (05 never, 15 a few times ayear; 25 a few times a month; 35 a few times aweek; 45 every day). High scores on the EE or Dsubscales were indicative of burnout, as do lowscores on the PA subscale [5]. A high level ofburnout was defined as a high level of EE (score of27 or higher), a high level of D (score of 10 orhigher), and a low level of PA (score of 33 or lower)based on normative data from a sample ofAmerican health professionals (physicians andnurses) [9,12]. We used these cut-off scores todetermine the levels of burnout.

Statistical analysis

All data were entered on an Excel (Microsoft,Redmond, WA) spreadsheet and analyzed by usingSPSS for Windows version10.0 (SPSS Inc.,Chica-go, IL, USA).Descriptive statistics are summarized by fre-

quencies and percentages for categorical, mean,and standard deviation for continuous variables.Independent samples t-tests or one-way analysis ofvariance was used to compare categorical variablesand MBI subscales between two groups. Bonfer-oni’s correction for multiple testing was performedby multiplying the p value with the number of testswhere appropriate.Pearson correlation coefficients were estimated

and tested for significance between continuouscovariates and MBI subscales.

Results

Seventy-seven physicians and 56 nurses weresurveyed and included in this study. The character-istics of the physicians and nurses are presented inTable 1. The mean age of physicians was higherthan that of nurses (32.1. vs 29.5. p5 0.03). Themajority of physicians were male, whereas allnurses were female. About half of the physiciansand nurses were married. All workers were workingin urban areas. All nurses were at clinic, while35/77 physicians were clinic personal, 32/77 physi-cians were academic personal. The length of workshifts for physicians was 6–14 h and for nurses was8–12 h. The physicians were working for 40–72 h,while nurses were working 40–60 h in a week. Thephysicians have seen on an average 30 patients aday. The nurses have seen 10 hospitalized patients

Copyright r 2008 John Wiley & Sons, Ltd. Psycho-Oncology 18: 543–548 (2009)

DOI. 10.1002/pon

544 A. Alacacioglu et al.

in a day. The mean of work experience (year) ofphysicians and nurses was similar (p40.05).The burnout level of physicians and nurses

according to MBI subscales are given in Table 2.Based on American normative data, 7.8% (6/77) ofthe physicians and 5.4% (3/56) of the nurses hadhigh EE and 15.6% (12/77) of the physicians and5.4% (3/56) of the nurses had high D scores. PAwas low in the majority of both health-careprofessionals. There were no statistical differencesbetween the two groups (p40. 05).Nurses had significantly higher scores of EE

(physicians: 15.477.1; nurses: 17.875.1, t5

�2.129, p5 0.035) when compared with the physi-cians, but no significant difference was foundbetween two groups regarding other burnoutcomponents (D: physicians: 5.673.6; nurses: 4.572.9, t5 1.748, p5 0.83; PA: physicians:21.774;nurses: 21.973,3, t5 1.307, p5 0.19).Significant correlations were found in three

different components of the MBI, as well asbetween each component, age and work experiencein nurses and physicians. Correlation analyses innurses are shown in Table 3. Correlation analysesin physicians showed that age was significantlypositively correlated with work experience, PA(r5 0.877, r5 0.406) and significantly negativelycorrelated with EE, D (r5�0.418, r5�0.377).Work experience was significantly negatively cor-related with EE, D (r5�0.322, r5�0.377) andsignificantly positively correlated with PA (r5

0.324) (Table 4).There were statistical significant differences in

each of the MBI subscales according to age groupsin physicians, but not in nurses (Table 5). EE andD were significantly higher in the p29 years agegroup than in the older age groups, while PA scorewas significantly lower in this age group, indicating

Table 1. The demographic characteristics of the physicians and nurses

Characteristics Physicians Nurses N % p�

Sex

Male 43 (55.8%) — 43 32.3

Female 34 (44.2%) 56 (100%) 90 67.7

Age (mean7SD) 32.177.7 29.576.4 0.03

Age

20–29 43 (55.8%). 39 (69.6%) 82 61,7

30–39 20 (26%) 10 (17.9%) 30 22.6

40–4 14 (18.2%) 7 (12.5%) 21 15.8

Marital status

Married 36 (46.8%) 25 (44.6%) 61 45.9

Single 41 (53.2%) 31 (55.4%) 72 54.1

Work experience (mean7SD) (year) 5.375.5 5.875.1 40.05

Work experience (year)

0–5 52 (67.5%) 29 (51.8%) 81 60.9

6–10 16 (20.8%) 24 (42.9%) 40 30.1

11–4 9 (11.7%) 3 (5.4%) 12 9

�Independent samples t-test.

Table 2. Levels of burnout in physicians and nurses

MBI subscales Physicians Nurses p

n 5 77 N (%) n 5 56 N (%)

High level of EE 6 (7.8) 3 (5.4) 40.05

High level of D 12 (15.6) 3 (5.4) 40.05

Low level of PA 77 (100) 56 (100) 40.05

EE, emotional exhaustion; D, depersonalization; PA, personal accomplishment.

Table 3. Correlations between age, work experience ,and MBIsubscales in nurses

Age Work experience EE D PA

Age 1

Work experience 0.682�� 1

EE 0.092 0.262 1

D 0.217 0.286� 0.355�� 1

PA .0127 0.004 �0.364�� 0.020 1

�Correlation is significant at the 0.05 level (two-tailed).��Correlation is significant at the 0.01 level (two-tailed).

EE, emotional exhaustion; D, depersonalization; PA, personal accomplishment.

Table 4. Correlations between age, work experience, and MBIsubscales in physicians

Age

Work experi-

ence EE D PA

Age 1

Work

experience

0.877�� 1

EE �0.418�� 0.322�� 1

D �0.377�� 0.377�� 0.757�� 1

PA 0.406�� 0.324�� 0.568�� 0.507�� 1

��Correlation is significant at the 0.01 level (two-tailed). EE, emotional

exhaustion; D, depersonalization; PA, personal accomplishment.

Burnout in nurses and physicians 545


DOI. 10.1002/pon

that younger physicians in our study groupexperienced high levels of burnout.Any significant differences regarding MBI sub-

scales were not found between male and female inphysicians (p40.05). EE, D, and PA were sig-nificantly higher in single physicians comparedwith married physicians (po0.001, p5 0.003, andpo0.001), but no significant difference was foundbetween single and married nurses regarding allMBI subscales (Table 6).

Discussion

The health workers who care for oncology patientsare themselves at risk for psychosocial stress andburnout. In our study, the prevalence of high levels

of D and EE subscales in physicians and nurses waslow according to existing studies [8,12,15]. PA waslow in the majority of both health-care profes-sionals. Any significant differences regarding pre-valence of all three MBI subscales were not foundbetween physicians and nurses. In the literature,the prevalence of the high-level EE, D, and lowlevel of PA were 53.3, 22.1, and 48.4%, respec-tively, in oncology physicians [16]. There are notnormative data available from a Turkish medicalpopulation. Previous studies suggest that levels ofwork-related stress and prevalence rates for burn-out are high among oncology physicians andnurses, though not necessarily higher than amongstaff in other clinical settings [8,12,15]. In a studyin Japan, the prevalence of the high-level EE and Dwas 22 and 11%. The prevalence of the low levelof PA was 62% in oncology physicians [8]. InAustralian study, the prevalence of the high-evel EE and D was 37 and 11% in oncologynurses. The prevalence of low level of PA was 20%in oncology nurses [17]. Comparing our findingswith that of these studies, it was found that theprevalence of the high-level EE and D was lowerthan other studies. However, the prevalence of thelow level of PA was higher. This may be relatedto the small number of study group or culturaland environmental differences. In Turkey, workenvironment, financial, and social factors thatmay affect the level of burnout in healthcareworkers in oncology department is taken intoconsideration [4].The level of EE of nurses was higher than

physicians significantly. However, there was nosignificant difference in other MBI subscales be-tween two groups. In an American study, radiationtherapists had significantly higher levels of the twoburnout subscales (EE, D) than that of nurses [11].In previous studies it was shown that burnout,particularly EE, was also strongly related to jobsatisfaction [4,18]. In this study, the causes of higherEE level of nurses than physicians may depend onmany factors such as emotional status, working

Table 5. MBI subscales according to age groups in physiciansand nurses

MBI sub-

scales

Age

groups�� N

Mean

rank

Chi-

square df p�

EE (Physicians) 1 43 48.42 17 529 2 o0.001

2 20 28.60

3 14 24.93

D (Physicians) 1 43 49.97 23 705 2 o0.001

2 20 26.13

3 14 23.71

PA (Physicians) 1 43 28.49 21 725 2 o0.001

2 20 51.53

3 14 53.39

EE (Nurses) 1 39 28.21 0078 2 40.05

2 10 28.55

3 7 30.07

D (Nurses) 1 39 27.01 1215 2 40.05

2 10 30.75

3 7 33.57

PA (Nurses) 1 39 26.77 1740 2 40.05

2 10 34.20

3 7 30.00

�One-way analysis of variance—Kruskal Wallis.��1: 20–29 years old, 2: 30–39 years old, 3: 40–49 years old.

EE, emotional exhaustion; D: depersonalization; PA: personal accomplishment.

Table 6. Sex, marital status, and MBI subscales in physicians and nurses

N (%) EE (mean7SD) D (mean7SD) PA (mean7SD)

Sex

Male 43 (55.8%) 14.477.3 5.774.1 22.374.2

Female 34 (44.2%) 16.776.8 5.473.1 20.973.8

(Physicians) p40.05 p40.05 p40.05

Marital status

Married 36 (46.8%) 12.577.1 4.574 23.474

Single 41 (53.2%) 1876.1 6.573.1 20.373.6

(Physicians) po0.001 p 5 0.003 po0.001

Marital status

Married 25 (44.6%) 17.976.2 4.572.8 9.773.9

Single 31 (55.4%) 17.774.2 4.573 10.173.4

(Nurses) p40.05 p40.05 p40.05

�Independent samples t-test. EE, emotional exhaustion; D, depersonalization; PA, personal accomplishment.



DOI. 10.1002/pon

time, or status. This may be related to being afemale and spending more time with patientsmay make her very sensitive to the events around.The mean work experience and work hour innurses were higher than the physicians in our studygroup.Increasing age and work experience in nurses

were not significantly correlated with MBI sub-scales while in physicians were significantly inver-sely correlated with EE, D, and positivelycorrelated with PA. Demir et al. found out thatPA levels increased with the total duration of workand highest levels of PA were observed for nurseswho have been working for 16 h or more [4]. In ourstudy the mean total duration of work for per daywas 10..4 h (SD: 1.8). Tselebis et al. assessed therelationships between burnout, depression, andsense of coherence in a large sample of Greeknurses. They found similar results with that of ourstudy. It was showed that depression was positivelycorrelated with EE and negatively with PA and nocorrelations between among MBI subscales andyears of work experience [19].The levels of burnout were significantly high in

younger physicians. The Finnish study resultsare opposite to ours. They found that age doesnot protect burnout [20]. Age might aggravatethe cumulative nature of job stress in today andolder age workers might run away from

the patients. This may be a reflection for ourresults.A limitation to this study design was surveyed

in a small number of nurses and physicians.However, the mean age, work experience, andwork hour per day were similar in both groups.Some demographic informations were notcollected sufficiently, such as length of work shifts,number of call nights per month, number ofhours worked per week, number of patients seenper day. Other limitations of our study were itscross-sectional nature and data collection method,which created difficulties in ascertaining causality.We used self-reported data collected at one point intime and did not evaluate psychological status suchas depression and also job satisfaction.In conclusion, low level of PA was relatively high

among Turkish physicians and nurses working inoncology department compared with previousstudies. Younger and single physicians had higherburnout levels compared with older and marriedones. Further studies should be evaluated theinterrelationships among burnout, job satisfaction,and psychosocial health.

Appendix

Maslach Burnout Inventory Scales

Maslach Burnout Inventory NEVER

A FEW TIMES A

YEAR

A FEW TIMES A

MONTH

A FEW TIMES A

WEEK

EVERY

DAY

1) I feel emotionally drained from my work.

2) I feel used up at the end of the workday.

3) I feel fatigued when I get up in the morning and have to face

another day on the job.

4) I can easily understand how my patients feel about things.

5) I feel I treat some patients as if they were impersonal objects.

6) Working with people all day is really a strain for me.

7) I deal very effectively with the problems of my patients.

8) I feel burned out from my work.

9) I feel I’m positively influencing other people’s lives through my

work.

10) I’ve become more callous toward people since I took this job.

11) I worry that this job is hardening me emotionally.

12) I feel very energetic.

13) I feel frustrated by my job.

14) I feel I’m working too hard on my job.

15) I don’t care what happens to some patients.

16) Working with people directly puts too much stress on me.

17) I can easily create a relaxed atmosphere with my patients.

18) I feel exhilarated after working closely with my patients.

19) I have accomplished many worthwhile things in this job.

20) I feel like I’m at the end of my rope.

21) In my work, I deal with emotional problems very calmly.

22) I feel patients blame me for some of their problems.

Emotional exhaustion: 1,2, 3, 6, 8,13,14, 16, 20 items. Depersonalization: 5, 10, 11,15, 22 items. Personal accomplishment: 4, 7, 9, 12, 17, 18, 19, 21 items.

Burnout in nurses and physicians 547


DOI. 10.1002/pon

References

1. Fredeunberger HJ. The issues of staff burnout intherapeutic communities. J Psychoactive Drugs 1986;18(3):247–251.

2. Maslach C. Burned-out. Hum Behav 1974;5:16–22.3. Maslach C, Goldberg J. Prevention of burnout: new

perspectives. Appl Prevent Psychol 1998;7:63–74.4. Demir A, Ulusoy M, Ulusoy MF. Investigation of

factors influencing burnout levels in the professionaland private lives of nurses. Int J Nurs Stud2003;40:807–827.

5. Ozyurt A, Hayran O, Sur H. Predictors of burnout andjob satisfaction among Turkish physicians. Q J Med2006;99:161–169.

6. Bettina FP. Burnout, role conflict, job satisfactionand psychosocial health among Hungarian health carestaff: a questionnaire survey. Int J Nurs Stud 2006;43:311–318.

7. Isikhan V, Comez T, Danis MZ. Job stress and copingstrategies in health care professionals working withcancer patients. Eur J Oncol Nurs 2003;8: 234–244.

8. Asai M, Morita T, Akechi T et al. Burnout andpsychiatric morbidity among physicians engaged inend-of-life care for cancer patients: a cross-sectionalnationwide survey in Japan. Psycho-Oncology 2007;16(5):421–428.

9. Whippen DA, Canellos GP. Burnout syndrome in thepractice of oncology: results of a random survey of1,000 oncologists. J Clin Oncol 1991;9(10):1916–1920.

10. Glasberg J, Horiuti L, Novais MA et al. Prevalence ofthe burnout syndrome among Brazilian medical oncol-ogists. Rev Assoc Med Bras 2007; 53(1):85–89.

11. Akroyd D, Caison A, Adams R. Burnout in radiationtherapists: the predictive value of selected stressors. Int JRadiation Oncol Biol Phys 2002;52(39):816–821.

12. Cam O. The burnout in nursing academicians inTurkey. Int J Nurs Stud 2001;38:201–207.

13. Ergin C. Adaptation and validity of MBI for measuringburnout among Turkish physicians and nurses. VIIthNational Psychology Congress, Turkish PsychologistsAssociation, Ankara, 1993.

14. Maslach C, Jackson SE, Leiter MP. Maslach BurnoutInventory Manual.: Consulting Psychologists Press: PaloAlto (CA), 1996.

15. Sherman AC, Edwards D, Simonton S, Mehta P.Caregiver stress and burnout in an oncology unit.Palliat Support Care 2006;4:65–81.

16. Grunfeld E, Whelan TJ, Zitzelsberger L, Willan AR,Montesanto B, Evans WK. Cancer care workers inOntario: prevalence of burnout, job stress and jobsatisfaction. CMAJ 2000;163(2):166–169.

17. Barrett L, Yates P. Oncology hematology nurses: astudy of job satisfaction, burnout, and intention to leavethe specialty. Aust Health Rev 2002;25,109–121.

18. Piko BF. Burnout, role conflict, job satisfaction andpsychosocial health among Hungarian health care staff:a questionnaire survey. Int J Nurs Stud 2006;43:311–318.

19. Tselebis A, Moulou A, Ilias I. Burnout versus depres-sion and sense of coherence: study of Greek nursingstaff. Nurs Health Sci 2001;3:69–71.

20. Ahola K, Honkonen T, Isometsa E et al. Burnout inthe general population. Results from the FinnishHealth 2000 Study. Soc Psychiatr Epidemiol 2006;41:11–17.



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Burnout in nurses and physicians working at an oncology department