Personal, social and behavioral components of emotional burnout among physicians (based on the example of a study of physicians in the Primorsky Territory)

Lyukshina Dar'ya Sergeevna Senior Lecturer of the Department of General Psychological Disciplines at Pacific State Medical University (PSMU) 690002, Russia, Primorskii krai, g. Vladivostok, pr. Ostryakova, 2 danyasergeevna@gmail.com Other publications by this author     Kapustina Tatiana Viktorovna ORCID: 0000-0001-9833-8963 PhD in Psychology Associate Professor, Department of General Psychological Disciplines, Pacific State Medical University under the Ministry of Health of the Russian Federation 690002, Russia, Primorsky Krai, Vladivostok, Ostryakova Ave., 2 12_archetypesplus@mail.ru Other publications by this author     Sadon Elena Vladimirovna PhD in Psychology Associate Professor, Department of General Psychological Disciplines, Pacific State Medical University under the Ministry of Health of the Russian Federation 690002, Russia, Primorsky Krai, Vladivostok, Ostryakova Ave., 2 elenasadon@yandex.ru

Kadyrov Ruslan Vasitovich PhD in Psychology Head of the Department of General Psychological Disciplines, Pacific State Medical University under the Ministry of Health of the Russian Federation 690002, Russia, Primorsky Krai, Vladivostok, Ostryakova Ave., 2 rusl-kad@yandex.ru Other publications by this author

The professional activity of doctors and medical specialists with continuous training, frequently changing working conditions, great emotional and physical stress, working with people, moreover, with people with various diseases, leads to the inevitable formation of emotional burnout ^{[2, 7, 11, 13, 29]}. Emotional burnout of doctors is a global problem. A review of the prevalence of emotional burnout among doctors in different countries showed the following results: in Russia (D.A. Samofalov et al.), its prevalence is 86%, according to the results of the study in all regions of the Russian Federation (a sample of 3370 subjects) ^[15], in China – 66.5-87.8% of specialists (a sample of 9302 people) ^[29], in the USA – 45.8% (sample of 7,288 doctors) ^[24], in India – 44.6% of medical specialists (2,026 people) ^[27], in France – 51% (1,500 subjects) ^[23], in South Africa – from 40 to 80% (1,200 respondents) ^[26]. At the moment, the World Health Organization has included burnout syndrome in the 11th revision of the International Classification of Diseases (ICD-11) as an occupational phenomenon, and not as a disease ^[32]. External working conditions naturally affect the development of emotional burnout, but to a greater extent conditionality is still associated with internal factors and components ^[5]. A sufficient number of studies have been conducted in the field of emotional burnout, including among doctors, but the topic remains acute and relevant. Different authors in different studies highlight a variety of internal factors /components that, according to researchers, are central to the formation of emotional burnout in doctors. Thus, A.F. Mingazov and co-authors identified two central factors – professional and personal ^[12]. Professional factors have more in common with the external conditions of work, personal factors are directly related to the personal life of the doctor and his values. A number of other authors are based on the individual psychological characteristics of the doctor, which may be favorable factors in the formation of emotional burnout, that is, be its accompanying components. The theoretical analysis of modern domestic research has allowed us to conclude that the main internal components of emotional burnout in medical professionals should be considered: a personal (emotional-volitional) component, which represents a spectrum of certain personal characteristics and conditions, a social component that influences and builds relationships with other people, including colleagues and patients, and behavioral component that determines the professional and motivational orientation of the individual and the ability to resist external influences. Most often, the following factors are distinguished, which can be correlated with the components. The social (interpersonal) component is interpersonal interaction, primarily between a doctor and a patient ^[13], especially if this interaction is destructive for a long time ^[11], as well as introversion ^[2]. Personal component – emotional state ^{[9, 13]}, emotional intelligence ^[25], the level of personal and situational anxiety ^{[4, 10, 11, 13, 16]}, depressive personality reactions ^{[4, 10, 13]}, emotional instability ^{[4, 10]}, aggressive tendencies ^[10], sensitivity ^[14], perfectionism ^[24]. Behavioral component – meaningfulness of life ^[21], propensity to rash statements and actions ^[2], stress resistance ^{[6, 10, 13, 16]}, internal professional motivation ^[9], internal resources for managing workloads ^[30]. To check how much from the position of this model it is possible to describe the features of emotional burnout, we will conduct an empirical study.

The aim of the work is to describe emotional burnout in doctors of Primorsky Krai by three components: personal, social and behavioral.

Organization and methods of research

The study involved doctors of different specialties working in different cities of Primorsky Krai. The total sample of the subjects was 340 people. The age of the respondents ranged from 25 to 71 years, according to this criterion, the subjects were divided into three groups: young age (25-35 years) – 97 people, mature age (36-60 years) – 179 respondents, and elderly age (over 60 years) – 64 people. The work experience of the subjects was also different, the whole set of respondents was divided into 4 subgroups: MOL – a young specialist (up to 10 years old, stage of professional adaptation) – 126 people; SR – a middle–aged specialist (11-20 years, stage of professional development) – 79 respondents; MAST - masters/experienced specialists (21-35 years, the stage of professional realization) – 103 respondents; PROF – professionals of retirement age (over 36 years, the stage of decline in professional activity) – 32 respondents.

To diagnose the severity of emotional burnout, the method "Definition of mental "burnout" by A.A. Rukavishnikov was used, the questionnaire diagnoses the manifestations of mental burnout at the interpersonal (social), personal and motivational (behavioral) levels. In addition to the main methodology , the following methods were also used: 1) questionnaire "SSPM-express" by V.I. Morosanova and I.N. Bondarenko to assess the level of self-regulation of doctors by identifying compensatory capabilities of the body, the technique determines the ability to resist external influences (behavioral); 2) Individual typological questionnaire (ITO) by L.N. Sobchik and 3) projective technique "12 archetypes plus" Kadyrova R.V., Kapustina T.V. to identify personal characteristics that doctors with different levels of emotional burnout may have, considering them as risk factors for its development (all three levels). For statistical processing of the results of the study, the method of frequency analysis, the median test, the nonparametric Kraskell-Wallis criterion were used with a significance level of no more than 0.05, calculations were carried out in the Statistica 10.0 program.

Results and their discussion

At the first stage of the study, a median test was conducted based on the results of the "Definition of mental burnout" technique, the data are presented in Table 1.

Table 1 – Results according to the method "Determination of mental burnout" by A.A. Rukavishnikov in the general sample of the studied

Doctors of medical organizations of Primorsky Krai have average values on the scales of psychoemotional exhaustion and personal distance. The reserve of their resources (emotional, physical, energy) for working with people is at an average level, signs of emotional and physical fatigue may begin to manifest with the transformation into fatigue, the beginnings of a manifestation of detachment, indifference with the desire to minimize contacts with others. The studied doctors of Primorsky Krai may have periods of irritability and negativism in situations of communication with patients, a desire to complete the work as soon as possible without focusing on its quality. But at the same time, medical workers have extremely high values on the scale of professional motivation, indicating a pronounced dominance of altruistic tendencies in work. Working with high dedication, responsibility, enthusiasm, an attitude to a constant workflow for the benefit of other people and completely forgetting about themselves, employees are rapidly moving towards a decrease in professional self-esteem, competence, degree of success and a high level of professional burnout. As evidenced by the high values on the scale of the index of mental burnout. This can manifest itself at all three levels: personal, social and behavioral. Both mental exhaustion, irritability, aggressiveness, hypersensitivity to the assessments of others, and unwillingness to contact people or cynical, negative attitude towards people, low emotional tolerance, low self-esteem and dissatisfaction with yourself as a professional.

As a result, the entire sample of 340 people studied was divided into 5 groups: extremely high level of emotional burnout – 146 people, high – 71 people, average – 92 people, low – 25 people, extremely low – 6 people. That is, emotional burnout is characteristic (from an average to an extremely high level) for 309 people (90.9%), which is a fairly high indicator. Due to the fact that among the studied medical specialists, a small number of people with low and extremely low levels of emotional burnout were identified, it was decided to combine them into one group, as well as extremely high with high indicators of the mental burnout index. Thus, the results were evaluated by comparing them in three groups – groups of doctors with a high level (217 people), with an average level (92 respondents) and a low level (31 people) of emotional burnout.

Table 2 – Results of statistical analysis conducted using the Kraskell-Wallis criterion and median test to compare the severity of personality traits in three groups with high, medium and low levels of emotional burnout

According to the results of statistical analysis using the method "Individual typological questionnaire" by L.N. Sobchik, significant differences were obtained on 8 scales out of 18 (Table 2). However, if we turn to the median test, the median values in different groups may not have differences at the level of the methodology. So, on the scale of Aggregation, the median for the three groups is 0, and for the scale of Conformity it is also not very significant (11/10/11). Therefore, the statistical differences obtained on these scales should not be considered. Thus, differences are noted on the remaining 6 scales – Aggressiveness, Introversion, Anxiety, Leadership, Individualism and Dependence.

For medical professionals with a low level of emotional burnout, an increase in test values on the scales of Aggressiveness and Leadership is more characteristic. The median on the Aggressiveness scale is 5 points, and for respondents with a high and average index of mental burnout – 4. Differences of 1 point is important at the level of methodology, since 5 points corresponds to accentuation, and 4 points – a personality trait without its obvious predominance. At the same time, 5 points is not a pronounced accentuation, which speaks and represents aggressiveness not in the context of aggressive and conflict behavior, but as a pronounced tendency to active self-realization, stubbornness and straightforwardness in defending their interests ^[17]. They also have more pronounced leadership traits (median 11) in comparison with medical specialists with a high level of emotional burnout (median 9), which manifest themselves in the form of independence in decision-making, entrepreneurship and the desire to be a leader, not a follower ^[19]. Probably, it is these personal characteristics that allow medical professionals to better withstand stressful influences and external pressure, not to give up when faced with difficulties, therefore they are less susceptible to emotional burnout.

For medical professionals with a high level of mental burnout, such scales as Introversion, Individualism, Addiction, and Anxiety are more pronounced. Increased introversion manifests itself in selectivity in communication, a tendency to limit the range of direct contacts ^{[17, 18]}, which is an unfavorable factor for professions of a socionomic profile for which interaction with other people is an important component ^[1]. Probably, interpersonal communication is difficult for them and requires significant internal resources, which are not unlimited, therefore it entails the severity of emotional burnout. Along with introversion, medical specialists show individualism and dependence, those traits that are to some extent opposite and create intrapersonal conflict. Individualism is more often manifested in the form of the stability of one's own opinion, different from the opinion of the majority, which entails stubbornness and unwillingness to agree with others. Dependence also manifests itself in vulnerability and sensitivity to external influences, the desire to avoid conflicts (like, "just don't touch me"). Also, increased dependence reveals a desire to have protection from a stronger personality, agreeing with her opinion ^{[18, 19]}. And here there is a confrontation, a person with a high level of emotional burnout does not always understand how to behave correctly, and the strategies of interpersonal interaction that manifest themselves do not always correspond to the situation (where it is not necessary, stubbornness may manifest itself – "I know how best, and I will do so," or, conversely, excessive dependence from external circumstances does not allow them to express perseverance and their opinion). This behavior contributes to the development of emotional burnout. At the same time, they have a pronounced Anxiety scale, characterized not only in anxiety itself, increased responsibility and over-caution in decision-making, but also in excessive suspiciousness, fearfulness, a tendency to obsessive fears, a maladaptive state ^[18]. A medical specialist who has this trait expressed is most likely overly responsible for solving professional tasks, greatly worrying and worrying about the outcome of their decisions, which contributes to the emergence of emotional burnout. Thus, the results according to the methodology of ITO L.N. Sobchik allowed us to describe the personal and social components of medical specialists with a high level of emotional burnout.

Let us turn to the results of the technique "Express Self-regulation Questionnaire" by V.I. Morosanova, which diagnoses the leading strategies for self-regulation of the state in stressful situations. The results of this technique will help to describe well the behavioral component of the manifestation of emotional burnout. The nonparametric Kraskell-Wallis criterion showed significant differences on 5 scales – Modeling, Programming, Reliability, Evaluation and the Overall level of self-regulation. However, the median test revealed differences at the level of methodology only in two – Modeling and Programming (Table 2). Thus, doctors with a high level of emotional burnout are characterized by a rare use of the modeling style and an average use of Programming. That is, we can say that they often have difficulties in determining the goal and program of actions adequate to the current situation, they do not always notice a change in the situation, which also often leads them to failures. They are not always able and willing to think through the sequence of their actions. Medical specialists with a high level of emotional burnout prefer to act impulsively, cannot always form an action program on their own, often face the inadequacy of the results obtained to the goals of the activity and at the same time do not make changes to the action program, act through trial and error. In these revealed behavioral features, the juxtaposition of individualism and dependence is also traced and confirmed. In general, they have a low or average level of manifestation of self-regulation styles. They still tend to plan their activities, but do not always consider it necessary to do so, however, they do not know how to act spontaneously, as the results of the study show, which increases the risk of emotional burnout, indicating inability to resist external influences and solve problems.

Statistical results on the projective technique "12 archetypes plus" by R.V. Kadyrov and T.V. Kapustina indicate that doctors with a high level of emotional burnout are characterized by rejection of the archetypes of the Innocent and the Wise (Table 2). The personal characteristics of the archetype of the Innocent are associated with optimism, positivity, cheerfulness, non-aggression, friendliness, trustfulness, lack of suspicion and criticality are manifested in relationships with others. An innocent person calmly perceives both good luck and bad luck, can be satisfied with any state of affairs ^[8]. Accordingly, these personality traits are not characteristic of medical professionals with a high level of emotional burnout, they are more pessimistic and fixated on failures, suspicious of reality, can look for a trick in any situation, critical of themselves and others. Denial of this archetype describes mainly the personal and social components of emotional burnout. The denial of the Sage archetype in people with a high level of emotional burnout indicates a lack of desire for self-realization, in search of new knowledge, alternative solutions to problems, they are not inclined to reflect and analyze their behavior in order to change and correct it, they are not characterized by emotional maturity and stability ^[8]. These manifestations indicate the personal and behavioral components of emotional burnout.

Thus, the results obtained made it possible to describe the internal factors of emotional burnout in medical professionals, including all three components.

At the second stage, statistical processing of the results was carried out based on the age of the subjects. The data obtained by the method "Determination of mental burnout" (A.A. Rukavishnikov) are presented in Table 3.

Table 3 – Results of the method "Determination of mental burnout" in different age groups

It is noteworthy that no statistically significant differences were found on the scales of "Psycho-emotional exhaustion" and "Professional motivation". The scale "Psycho-emotional exhaustion" characterizes the process of exhaustion of emotional, physical, and energy resources of a professional working with people. It can be assumed, and this is confirmed by theoretical analysis, exhaustion manifests itself in chronic, emotional and physical fatigue, indifference and coldness towards others, with signs of depression and irritability regardless of age. The results also indicate that the level of altruistic motivation and enthusiasm for work is independent of age. The state of the motivational sphere of medical workers is assessed by such indicators as the productivity of professional activity, optimism and interest in work, self-assessment of professional competence and the degree of success in working with people. All of these factors are expressed in the medical workers taking part in the study, which indicates a willingness to work with high dedication, responsibility, and an attitude to a constant workflow, regardless of age. As for the "Personal Distance" scale, which illustrates a specific form of social maladaptation of a professional working with people, the analysis of the results revealed differences in different age groups. This form of social maladaptation turned out to be more characteristic of young and mature age groups, and at a high level. The data obtained do not contradict the results of other studies ^[20], and a similar conclusion is demonstrated by representatives of various professions of the "man-man" type. These age periods are characterized by solving very important problems of professional formation: adaptation to social and professional norms and conditions, work processes, coordination of life and professional goals and attitudes, the formation of significant personality traits of a professional, the development of professionally important qualities, special abilities, emotional and volitional qualities. During the same period, a person solves his personal tasks of building a family and raising children, and this process is not always positive. It can be assumed that the totality of various professional and personal problems, despite the seemingly high reserve of vitality inherent in the most productive age period, requires a person to concentrate and develop certain ways to solve emerging life problems of a wide range. The efforts needed to overcome the difficulties encountered often exceed the available resources, which leads to manifestations of social maladaptation. Also, a possible cause of burnout for young respondents may be a discrepancy between expectations related to the profession and reality. Young professionals, coming to work, face various situations for which they are not internally prepared, as a result of which there is a feeling of their own incompetence, frustration and disappointment. The high result on the scale of "Personal distance" for respondents who entered the group of mature age can be associated with the peculiarities of age, namely, with a mid-life crisis partially coinciding with this age. At about this age, a person looks back, evaluates the past, evaluates his professional achievements in the form of status, position, salary increase, etc. In this regard, he begins to experience emotional discomfort, mental stress, dissatisfaction with work, fatigue. And, perhaps, this may be one of the prerequisites for the formation of an emotional burnout syndrome. A high level of professional burnout among medical workers is manifested in a negative, covertly aggressive attitude towards patients, a critical, evaluative attitude towards them ^[22].

It is noteworthy that the group of doctors over 60 years of age has lower indicators relative to other age groups on the scale of "Personal distance", which is also consistent with the results of published studies ^[20]. In this age period, the professional's motives for his activities change, the means of their implementation, there is a reassessment of values, a person strives for a certain stability in life. Full or partial realization of professional potential, stabilization of the main operational structures, personality traits are, as a rule, stable, the personality image is built, compensation for some mental functions is well expressed, life goals are adjusted. It can be assumed that, despite the signs of a decrease in activity, medical workers for a long time retain not only the professional orientation of life, but also psychological and professional potential, personal orientation to productive work. The same conclusions can be an explanation for the achieved average values of the mental burnout index in the elderly group compared with high values in other groups.

At the third stage, statistical processing of the results was carried out based on the work experience of medical specialists (Table 4).

Table 4 – Results of the method "Determination of mental burnout" in groups with different work experience

Analysis of the results of the severity of emotional burnout by experience showed that there were no statistically significant differences in our sample. Thus, we can agree with the researchers' conclusions that the relationship of work experience in the medical field with the parameters of emotional burnout is not so unambiguous ^[3]. Firstly, work experience in the medical field is always very closely related to age, since the training of a medical worker requires long-term training and subsequent specialization in practice. And the connection of emotional burnout with age was revealed in our study. Secondly, the transition from other fields of activity to medical is almost not found (whereas, on the contrary, it is often). Therefore, it can be assumed with high probability that seniority and age are linked factors in relation to medical workers and when continuing research on the relationship between seniority and emotional burnout, it is necessary to take into account seniority related specifically to work in the healthcare sector.

Conclusion

Thus, the data obtained in the course of an empirical study of doctors working in the Primorsky Territory allow us to describe the manifestations of emotional burnout from the perspective of various components.

The personal (emotional-volitional) component of doctors with a high level of emotional burnout is characterized by increased anxiety, suspiciousness, fearfulness, and a tendency to a maladaptive state. They are pessimistic and fixated on failures, suspicious of reality, can look for a trick in any situation, critical of themselves and others. They show emotional immaturity and instability, there is a decrease in professional self-esteem and competence.

The social (interpersonal) component of doctors with a high level of emotional burnout, first of all, manifests itself in the form of introversion, selectivity, indifference in communication, a tendency to limit the circle of direct contacts, interpersonal communication is difficult for them and requires significant internal resources, periods of irritability and negativism appear in situations of communication with patients. There is also an intrapersonal conflict, reflected in the simultaneous manifestation of individualism and dependence on others, that is, a confrontation is detected, a person does not always understand how to behave correctly, and the strategies of interpersonal interaction that manifest themselves do not always correspond to the situation. Where it is not necessary, stubbornness may manifest itself – "I know what is best, and I will do it," or, conversely, there is excessive dependence on external circumstances, which does not allow them to express perseverance and their opinion.

The behavioral (motivational-value) component of doctors with a high level of emotional burnout is manifested as follows: they often have difficulties in determining the goal and program of actions adequate to the current situation, they do not always notice a change in the situation, which also often leads them to failures. They are not always able and willing to think through the sequence of their actions, prefer to act impulsively, through trial and error. There is a low or average level of manifestation of self-regulation styles. It is important to note the lack of desire for self-realization, in search of new knowledge, alternative solutions to problems, they are not inclined to reflect and analyze their behavior in order to change and correct it.

In addition, during the study it was determined that the total work experience does not correlate in any way with the manifestations of emotional burnout, and age, in particular, young and mature, in contrast to the elderly, contributes to it.

The obtained data and descriptions determine the target points for the prevention and psychological correction of emotional burnout in doctors of different specialties. And within the framework of continuous training, this can be done in the form of advanced training programs for doctors.