医生职业倦怠 英文

Copyright © 2007 John Wiley & Sons, Ltd.R e l a t i o n s h i p b e t w e e n j o bb u r n o u t a n d oc c u p a t i o n a ls t r e s s a m o n g d o c t o r s i n C h i n aSiying Wu,1,*,†,‡ Wei Zhu,2,‡ Huangyuan Li,3 Zhiming Wang 4 and Mianzhen Wang 41 Department of Epidemiology and Health Statistics, School of Public Health, FujianMedical University, Fujian, P. R. China 2 Department of Social Medicine, College of Public Health, Zhengzhou University, Henan,P. R. China 3 Department of Occupational and Environmental Medicine, School of Public Health,Fujian Medical University, Fuzhou, Fujian, P. R. China 4 Department of Occupational Health, West China School of Public Health, SichuanUniversity, Sichuan, P. R. China* Correspondence to: Siying Wu, Department of Epidemiology and Health Statistics, Major Subject of Environment and Health of Fujian Key Universities, School of Public Health, Fujian Medical University, NO 88 of Jiaotong Road, Fuzhou 350004, Fujian Province, P. R. China.† E-mail: fmulhy@‡ Both authors contributed equally to this work.Contract/grant sponsor: National Natural Science Foundation.Contract/grant number: 39970623.S t r e s s a n d H e a l t hStress and Health 24: 143–149 (2008)Published online 6 December 2007 in Wiley InterScience (). DOI: 10.1002/smi.1169Received 9 February 2007; Accepted 18 September 2007SummaryThe purpose of this study was to explore the status of the job burnout of doctors and the variables associated with this in China. The sample consisted of 543 doctors from three provincial hospitals in China. The Maslach Burnout Inventory-General Survey (MBI-GS) was used to measure burnout, and the occupational stress inventory revised edition was used to measure the two dimensions of occupational adjustment (including occupational stress and coping resources). After the statistical testing for validity and reliability of MBI-GS with nurses in China, the participants’ scores were evaluated and analysed. The main results were as follows. The scores of job burnout of the surgeon and physician were signifi cantly higher than the others (p < 0.05). The score of exhaustion (EX) was signifi cantly higher in the 30- to 40-year age group than that in any other groups. The score of professional effi cacy (PE) decreased with age, while this increased with educational status. Occupational stress was signifi cantly positively related to all burnout dimensions (p < 0.05), while coping resources correlated negatively to all burnout dimensions. Under multilevel regression, the main signifi cant predictors of EX were role overload, responsibility, physical environment and self-care. The main signifi cant predictors of cynicism were role insuffi ciency, role overload and respon-sibility, and of PE were role insuffi ciency, social support and rational/cognitive coping (p < 0.05). Organizational efforts aimed at reducing occupational stress and strengthening their coping resources among doctors could help prevent job burnout. Copyright © 2007 John Wiley & Sons, Ltd.Key Wordsburnout; doctor; Maslach Burnout Inventory-General Survey; occupational stress; ChinaS. Wu et al.Copyright © 2007 John Wiley & Sons, Ltd. Stress and Health 24: 143–149 (2008)DOI : 10.1002/smi 144IntroductionBurnout, a phenomenon that is of interest for bothindividuals and organizations, is characterized bydecreasing energy, power and resources in thepresence of excessive demands. Burnout, causedby the cumulative effect of the stressful workingenvironment, that exceeds the coping capabilityof the workers, is a state which forces the staffto become introverted. According to Maslach,burnout is most commonly defi ned as a syndromeof feelings of emotional exhaustion, depersonal-ization and reduced personal accomplishment(Schaufeli & Buunk, 1996). Schwab, Jackson, andSchuler (1986) reported that burnout was hypoth-esized to be associated with both unmet employeeexpectations and job conditions.It is well known that burnout is a major problemfor many professions; it has been studied amongnurses, psychologists, teachers, policemen, physi-cians, human service professionals, managers andmany other professionals (Schaufeli, Enzmann,& Girault, 1993). Measuring burnout amongdoctors is important because their well-being hasimplications for stability in the health care pro-vider workforce and for the quality of care itprovides. Burnout resulting from occupationalstress may lead to the intent to change workinvolvement or leave the workforce (Gaines &Jermier, 1983; Maslach, Jackson, & Leiter, 1996;Williams et al., 2001). Burnout among physiciansmay also affect patient satisfaction and treatmentcompliance (Maslach et al., 1996; Williams et al.,2001).n modern society, occupational stress is acommon problem in people’s working life. It is aconsequence of a combined exposure to a multi-tude of factors in the work environment andemployment conditions. The Health and SafetyExecutive (2001) further described how ill-health(both physical and mental) can result if occupa-tional stress is prolonged or intense. Excessivestress has been shown to increase the risk ofmental and physical health problems (Karasek &Theorell, 1990), to increase the risk of seriousoccupational injury (Salminen, Kivimaki,Elovainio, & Vahtera, 2003; Trimpop, Austin, &Kirkcaldy, 2000; Trimpop, Kirkcaldy, Athanasou,& Cooper, 2000) and to decrease the employees’work ability. Occupational stress among doctorshas regularly been the subject of research in thelast two decades. One of the possible conse-quences of chronic occupational stress is jobburnout (Freudenberger, 1974).As a result of chronic emotional and inter-personal stress on the job, the phenomenon of burnout has become a focus to more and more researchers. Nevertheless, many western counties have undertaken both theoretical and empirical studies on burnout in the past 30 years; domestic researches are limited to the introduction of western research conclusions and theories without application and demonstration. I t is important for us whether the instrument of burnout based on western culture can be well applicable in the background of China. Furthermore, only a few studies have examined the relationship between burnout and occupational stress. The purposes of this current study were threefold: (1) to evaluate the level of job burnout among doctors in China; (2) to explore the relationships between job burnout and occupational stress; and (3) to give some suggestions to the hospital managers and to provide a theoretical reference for preventing job burnout and improving the quality of working life.Materials and methods Sample and procedure A convenience sample of staff doctors were recruited from three provincial hospitals of Henan province in China in 2006. Of the 647 doctors contacted, 543 (84 per cent) returned their com-pleted questionnaires; 56.9 per cent of the sub-jects were male. The mean age was 37 years [standard deviation (SD) = 6 years] with a range from 20 to 65 years. The number of participants for each setting was 155 (surgery), 162 (medi-cine), 71 (oncology), 84 (cardiology), 52 (neona-tal care) and 19 (clinical laboratory). Some subjects were sampled from one of the three pro-vincial hospitals using a random cluster sampling method to examine the reliability and validity of the inventory.The study was implemented with the help of the hospital leaders. After a brief introduction to the study, a questionnaire regarding the demographic characteristics of the physicians, the Maslach Burnout I nventory-General Survey (MB I -GS) (Schaufeli, Leiter, Maslach, & Jackson, 1996) and the Occupational Stress Inventory Revised Edition (OS I -R) (Osipow, 1998) were all administered during face-to-face interviews.Job burnout and occupational stress among doctors in ChinaCopyright © 2007 John Wiley & Sons, Ltd. Stress and Health24: 143–149 (2008)DOI: 10.1002/smi 145Measurement toolsThe MBI-GS.Burnout was assessed using the MBI-GS (Schaufeli et al., 1996). This instrument can be used in a variety of occupations. The MBI-GS consists of 16 items and has three subscales representing emotional exhaustion (EX, fi ve items, e.g. ‘working all day is really a strain for me’, 0 = never, 6 = everyday); cynicism (CY, fi ve items, e.g. ‘I doubt the signifi cance of my work’, 0 = never, 6 = everyday); and professional effi cacy (PE, six items, e.g. ‘I have accomplished many worthwhile things in this job’, 0 =never, 6 = everyday). The higher the score of MBI-GS, the stronger the job burnout is.One should be extremely cautious when using the cut-off points for the classifi cation of burnout levels as these points vary from country to country because of many social and cultural reasons. The MBI-GS, which is originally in English, was trans-lated into Chinese by a group of 10 professors from the nursing and medicine fi elds. In order to test the language validity, the obtained Chinese version of the MBI-GS was translated back to English by another group of 10 professors. Then, the Chinese version was reviewed. Having applied this version to a sample group of 30 doctors as a pre-research, it was concluded that the obtained Chinese version was highly valid for use.Since the differences in culture, society and others could infl uence the validity and reliability of the MBI-GS, 319 subjects were sampled from one of the three provincial hospitals using a random cluster sampling method to examine the reliability and validity of the inventory. Several statistical tests were applied. Firstly, Cronbach’s alpha values were calculated for the MBI-GS. Secondly, the test/retest method was carried out; after 2 weeks, the MBI-GS forms were completed again by the same sample group of 219 partici-pants as a retest. Thirdly, the correlation coeffi -cients between the score of MB-GS and its subscales were calculated. Finally, the structural validity was tested by means of factor analysis. OSI-R (Osipow, 1998).The OSI-R is a concise measure of the three dimensions of occupational adjustment: occupational stress, psychological strain and coping resources. For each of these domains, scales measure specifi c attributes of the environment or individual that represents impor-tant characteristics of occupational adjustment.I n this study, two questionnaires in the OSI-R were used, including the Occupational Role Ques-tionnaire (ORQ, including ‘role overload’, ‘role insufficiency’, ‘role ambiguity’, ‘role boundary’, ‘responsibility’ and ‘physical environment’; six scales, 10 items per scale) and the Personal Resources Questionnaire (PRQ, including ‘recre-ation’, ‘self-care’, ‘social support’ and ‘rational/ cognitive coping’; four scales, 10 items per scale). The higher the score of ORQ, the stronger the stress level is, while the higher the score of PRQ, the more abundant the coping resource is. The OSI-R had been translated into Chinese and con-fi rmed to have good reliability and validity (Wang, Lan, Li, & Wang, 2000).Statistical analysisAll the data were input with the aid of Foxpro 6.0, and all statistical analyses were performed using the SPSS 11.5 for Windows statistical package and LI SREL version 8.54. Because the distribution of the sample mean is nearly normal with the large sample size of this study, paramet-ric statistics were used on the index scores. Data were presented as mean ± SD, with a two-tailed at p< 0.05 to be considered signifi cant. The factor analysis and confirmatory factor analysis were used to test the construct validity of MBI-GS. The structural equation modelling program was used to assess the factor structure of the MBI-GS; the model fit was assessed using the χ2/degrees of freedom (df), as well as the Normed Fit I ndex (NFI), the Relative Fit Index (RFI), the root mean squared residual (RMR), the Comparative Fit Index (CFI) and other indices. The lower the χ2/ df, RMR and root mean square error of approx-imation are, the better the model fi t; the higher other indices are, the better the model fi t. The inter-item consistency, retest reliability and analy-sis of correlation were used to test the reliability of MBI-GS. Other statistical procedures included descriptive analysis and multiple linear regression analysis.ResultsInstrument validationCronbach’s alpha values were obtained for EX (EX =0.874), CY (CY =0.801) and PE (PE = 0.711). The retest results demonstrated a reliable test/retest consistency (EX, r=0.740, p<0.01; CY, r= 0.666, p< 0.01; PE, r= 0.706, p< 0.01).S. Wu et al.Copyright © 2007 John Wiley & Sons, Ltd. Stress and Health 24: 143–149 (2008)DOI : 10.1002/smi146The correlation coeffi cients between the score ofthe MBI-GS and its subscales ranged from 0.579to 0.788 (p < 0.01). Following the principle com-ponent analysis, promax rotation showed that thefactor structure of MBI-GS was well established(Table I ). Further analyses revealed that three-factor models were better than one-factor modeland the results based on a 15-item version of theMBI-GS (without item 13) were similar to thosebased on the full 16-item version in the three-factor models for the data. Thus, rewording item13 did not seem to affect the results (Table II). Allthese results indicated that the measurementmodel was highly valid.Burnout studyAs it is seen in Table I I I , it was found that thedifferences among the EX, CY and PE scoremeans for different age, different educationalstatus and different department were statisticallysignifi cant (p < 0.05). The scores of job burnoutof the surgeon were signifi cantly higher thanothers (p < 0.05). The score of EX was signifi -cantly higher in the 30- to 40-year age group than that in any other groups. The score of PE decreasedwith age, while it increased with educational status. However, the score means of EX, CY and PE did not differ in age (p > 0.05, Table III).The relation between occupational stress and job burnout was examined using correlations between both variables. As can be seen in Table IV, occupational stress was signifi cantly positively correlated with all burnout dimensions, and coping resources were inversely correlated with the three dimensionalities of job burnout (p < 0.05).The variables examined in the study were as follows: age, professional experience, marital status, educational status, occupational stress and personal resources. The contributions of the vari-ables mentioned above to the subscale scores of the MBI-GS were examined by the stepwise mul-tiple regression analysis. The results are listed in Table V. The regression analysis revealed different sets of predictors for each of the three burnout scales. Emotional EX was best predicted by role overload, responsibility, physical environment, recreation and self-care. This set of predictors accounted for 47.5 per cent of the variance (adjusted R 2) in emotional EX. CY was best pre-dicted by role insuffi ciency, role overload and responsibility, which accounted for 32.5 per cent Table I. Items and their factor loadings.I 1 0.876 2 0.779 4 0.701 13 0.8903 0.834 7 0.760 6 0.5455 0.726 8 0.820 9 0.77711 0.856 15 0.773 10 0.52714 0.667 12 0.70716 0.580Factor 1 stands for exhaustion (EX); factor 2 stands for cynicism (CY); factor 3 stands for professional effi cacy (PE); factor 4stands for the other subscales (isolation).Table II. Goodness-of-fi t indices for the structural models.χ2 df χ2/df RMR NF I RF I I F I CF I RSMEA The model of one factor758.41 104 7.29 0.13 0.61 0.55 0.64 0.64 0.180The model of three factors (1)*228.74 101 2.26 0.06 0.88 0.85 0.92 0.92 0.063The model of three factors (2)† 190.00 87 2.18 0.05 0.89 0.87 0.94 0.93 0.061* Including whole item.† Excluding item 13.χ2: chi-square; df: degrees of freedom; RMR: root mean squared residual; NFI : Normed Fit I ndex; RFI : Relative Fit I ndex;IFI: Incremental Fit Index; CFI: Comparative Fit Index; RSMEA: root mean square error of approximation.Job burnout and occupational stress among doctors in ChinaCopyright © 2007 John Wiley & Sons, Ltd. Stress and Health 24: 143–149 (2008)DOI : 10.1002/smi 147Table III. The level of the doctors’ job burnout in different demographic character.n Exhaustion Cynicism Professional effi cacySexMale 309 9.49 ± 4.51 10.9 ± 6.26Female 234 9.7 ± 5.13 10.3 ± 5.61t 1.034 0.611 1.192Age groups<30 103 8.7 ± 4.80 8.7 ± 5.14 12.6 ± 5.4330∼ 278 10.3 ± 5.18 9.8 ± 4.71 10.0 ± 6.1140∼ 162 9.4 ± 5.49 9.6 ± 5.72 8.6 ± 5.24F 4.052* 1.917 16.529**Educational statusHigh school or below 370 9.6 ± 5.46 9.5 ± 5.28 9.7 ± 5.58College and above college 173 9.7 ± 4.74 9.6 ± 4.74 12.4 ± 6.16t 0.213 0.288 5.020**DepartmentMedicine 201 10.0 ± 5.12 9.8 ± 4.88 10.2 ± 5.57Surgery 149 10.6 ± 5.76 10.1 ± 5.14 9.5 ± 5.75Other 193 8.6 ± 4.76 8.8 ± 4.76 11.9 ± 6.15F 6.938** 3.636* 7.732*** p < 0.05; ** p < 0.01.Table IV. Correlation analysis for burnout and occupational stress.Occupational Stress Inventory Revised Edition Maslach Burnout Inventory-General SurveyExhaustion Cynicism Professional effi cacyRole overload 0.562** 0.408** 0.043Role insuffi cient 0.190** 0.281** 0.262**Role ambiguity 0.195** 0.244** 0.232**Role boundary 0.188** 0.217** 0.195**Responsibility 0.375** 0.254** −0.055Physical environment 0.313** 0.219** −0.202**Recreation −0.360** −0.107* −0.088*Self-care −0.261** −0.143** −0.239**Social support −0.077 −0.122** −0.335**Rational/cognitive −0.337** −0.164** −0.261*** p < 0.05; ** p < 0.01.Table V. Predictors of the three dimensions of burnout.Infl uence factors Exhaustion Cynicism Professional effi cacy Role overload 0.275 0.274 9.834** 0.165 0.172 5.753**Role insuffi cient 0.106 0.095 3.501** 0.292 0.274 9.630** 0.206 0.133 4.385**Role boundary 0.101 0.077 2.419*Responsibility 0.094 0.105 3.831** 0.124 0.145 4.850** −0.134 −0.108 3.592**Physical environment 0.123 0.151 6.101** 0.067 0.086 3.196** −0.092 −0.081 2.946**Recreation −0.124 −0.133 4.686**Self-care −0.098 −0.102 3.504**Social support 0.088 0.092 3.228** −0.070 −0.076 2.706** −0.225 −0.169 5.107**Rational/cognitive −0.134 −0.163 5.221** −0.185 −0.162 5.032*** p < 0.05; ** p < 0.01.1 B = Unstandardized coeffi cients.2 Beta = Standardized coeffi cients.S. Wu et al.Copyright © 2007 John Wiley & Sons, Ltd. Stress and Health 24: 143–149 (2008)DOI : 10.1002/smi148of the variance. For the PE dimension, role insuf-fi ciency, social support and rational/cognitivecoping together explained 27.8 per cent of thevariance.DiscussionJob burnout is a psychological syndrome thatinvolves a prolonged response to stressors in theworkplace. Specifi cally, it involves the chronicstrain that results from an incongruence, or misfi t,between the worker and the job (Maslach, 2003).Excessive stress has been shown to increase therisk of mental and physical health problems (suchas fatigue, anxiety, depressive, job burnout, etc.)and to decrease the employees’ work ability. I thas also been argued that occupational stress isa very severe impact on both individual andorganization.This study should be regarded as a preliminaryattempt to explore the relationships among jobburnout and coping resource and occupationalstress in China. It is important not only in termsof being the fi rst study in this fi eld in China, butalso because of using the MBI-GS after testing itsvalidity and reliability in doctors in China. In thisstudy, it was initially assessed whether the MBI-GS form has validity and reliability among thedoctor sample, and the results indicated that theMB -GS is valid and can be applied reliablyamong Chinese doctors. The fi ndings indicatedthat the doctors commonly experienced burnout.Gender has not been a strong predictor of burnout,while the scores of the subscales of job burnoutshowed signifi cant differences in different age,educational status and department. The threedimensions of burnout are related to the work-place variables in a different way. The predictorsrelated to each of the three subscales of MBI-GSwere, in the order of the strength, as follows. Foremotional exhoustion, the strongest predictorwas found to be role overload, responsibility,physical environment, recreation and self-care.For cynicism, the strongest predictor appeared tobe role insuffi ciency, role overload and responsi-bility. For the third component, professional effi -cacy, the predictors in the order of strength arerole insuffi ciency, social support and rational/cog-nitive coping. Role overload measures the extentto which job demands exceed resources and theextent to which the individual is able to accom-plish workloads; role insuffi ciency measures theextent to which the individual’s training, educa-tion, skills and experience are appropriate to job requirements; responsibility measures the extent to which the individual has or feels a great deal of responsibility for the performance and welfare of others on the job; physical environment mea-sures the extent to which the individual is exposed to high levels of environmental toxins or extreme physical conditions. The higher the score of the four scales, the stronger the stress level is. Recre-ation measures the extent to which the individual makes use of and derives pleasure and relaxation from regular recreational activities; self-care mea-sures the extent to which the individual regularly engages in personal activities which reduce or alleviate chronic stress; social support measures the extent to which the individual feels support and help from those around him/her; rational coping measures the extent to which the indi-vidual possesses and uses cognitive skills in the face of work-related stresses. The higher the score of the four scales, the more abundant the coping resource is. So, reducing occupational stress in medical personnel and strengthening their coping resources may be effi cient intervention measures for preventing job burnout and improving their quality of life.The fi ndings of this study provide support for the hypotheses that greater work-related stress and coping resource would be associated with burnout in doctors. Thus, information on factors infl uencing doctors’ feelings of burnout, such as coping resources, can be used to improve their psychological health. For example, social skill training has been shown to improve people’s interpersonal problem-solving and practical skills (Spence, 1994). Therefore, it could be introduced into doctors’ basic training to improve their coping skills. On the other hand, burnout is a complex phenomenon and it is likely that it is infl uenced by many social, psychological and environmental factors. Further studies will need to determine the relative impact of these vari-ables. We believe that improvements especially on occupational stress and coping resources predic-tors will lead to a considerable progress in com-bating burnout among doctors in China.Attention should be called that this research is not without limitation. Firstly, the measures were obtained from the doctors’ self-reports and may, therefore, refl ect bias in the reporting of different model variables. Secondly, the doctors may under-estimate or overestimate their levels of burnout and work-related stress. Therefore, a further step might be to fi nd ways of exploring the causalJob burnout and occupational stress among doctors in ChinaCopyright © 2007 John Wiley & Sons, Ltd. Stress and Health24: 143–149 (2008)DOI: 10.1002/smi 149connection between occupational stress and burnout. For example, further studies might be carried out where doctors are trained to reduce their occupational stress.ConclusionAccording to our fi ndings, intervention pro-grammes aimed at preventing or reducing burnout among doctors, may focus upon reducing occu-pational stress and strengthening their coping resources. 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