PREVALENCE AND ASSOCIATED RISK FACTORS AMONG US DOCTORS OF CHIROPRACTIC
OF
BURNOUT
Shawn P. Williams, DC, PhD, a and Genevieve P. Zipp, PT, EdD b
ABSTRACT Objective: The purpose of this study was to establish the frequency of burnout among doctors of chiropractic in the United States. Methods: Using a nonprobability convenience sampling methodology, we e-mailed the Maslach Burnout Inventory– Human Services Survey and a sociodemographic questionnaire to a randomized sample of licensed doctors of chiropractic (n = 8000). Results: The survey return rate was 16.06%. Twenty-one percent of the participants had high emotional exhaustion (EE), 8% had low personal accomplishment, and 8% had high depersonalization. Discussion: Significant differences (P b .001) were found in the level of EE, depersonalization, and personal accomplishment as a function of sex, time dedicated to clinical care and administrative duties, source of reimbursement, the type of practice setting, the nature of practitioners' therapeutic focus, the location of chiropractic college, self-perception of burnout, the effect of suffering from a work-related injury, the varying chiropractic philosophical perspectives, and the public's opinion of chiropractic. Conclusion: Although doctors of chiropractic in the United States who responded to the survey had a relatively low frequency of burnout, higher levels of EE remain workplace issues for this professional group. (J Manipulative Physiol Ther 2014;37:180-189) Key Indexing Terms: Prevalence; Burnout, Professional; Chiropractic
ainstream health care and governmental organizations such as the World Health Organization consider chiropractic to be complementary and alternative medicine. 1 The chiropractic profession is the largest complementary and alternative medicine profession 2 and one of the largest licensed health care professions in the United States. 3 Reports from chiropractic governing bodies, trade magazines, and research proceedings suggest that although the practice of chiropractic can be remarkably meaningful and personally gratifying, it is also arduous and stressful. 4-10 Researchers investigating burnout agree that health care professionals (allopathic physicians, nurses, and various rehabilitation therapists) have a high potential for developing stress and consequently burnout. 11-13 Burnout is a “psychological syndrome” 14,15 that entails a feeling of
M
a
Assistant Professor, Department of Health Professions, CUNY–York College, Jamaica, NY. b Professor, Graduate Programs in Health Science, Seton Hall University, South Orange, NJ. Submit requests for reprints to. Shawn P. Williams, DC, PhD, Assistant Professor, 94-20 Guy R. Brewer Blvd, SCI 115, Jamaica, NY 11451 (e-mail: [email protected]). Paper submitted August 14, 2013; in revised form November 16, 2013; accepted November 20, 2013. 0161-4754/$36.00 Copyright © 2014 by National University of Health Sciences. http://dx.doi.org/10.1016/j.jmpt.2013.12.008
180
being emotionally overextended and exhausted by one's work (emotional exhaustion [EE]), a negative and/or cynical attitude that provokes impersonal feelings toward one's clients (depersonalization [DP]), and a sense that one is achieving little—hence having low productivity (reduced personal accomplishment [PA]). Because doctors of chiropractic (DCs) face many of the same stressors and/or challenges as other health care providers with decreased reimbursement, changing patient payer types, changing patient and payer expectations, and diminished profit margins, 16-19 they also face unique set of profession-specific stressors such as philosophical dissonances, unconstructive public perception, increased market competition (both internally and externally), a relatively high prevalence of work-related injuries and a high student loan default rate. 5,8-10 Common challenges within the health care arena, combined with the noted chiropracticspecific stressors and the chronic work-related stressors of caring for individuals, may pose a hazard to the DC at risk for developing burnout. Results from a recent study 20 support the abovedescribed notion that DCs face unique profession-specific stressors (such as the professions' public perception and philosophical inconsistencies) that appear to have an association with their subsequent burnout indices. Although the study (n = 90) was limited to the northeastern region of the United States, the moderate levels of EE (the core
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element of burnout) 21 revealed in this cohort support the need to further explore the regional differences that may contribute to the stressors responsible for burnout in DCs across the United Sates. A larger study might help identify precipitating factors (ie, academic preparation and scope of practice) of professional burnout and thus help generate a dialogue on improving the quality of professional life for DCs. Therefore, the purpose of this study was to establish the frequency of burnout among DCs in the United States.
METHODS This study was exploratory descriptive in nature and involved the use of cross-sectional data collection as a means of understanding the prevalence of burnout among DCs. An e-mail letter of invitation with a hyperlink to an online version of the survey was sent to the randomized sample of 8000 DCs (as provided by MPA Media; http://www. mpamedia.com/). As such, the accessible population was defined as any DCs with an e-mail address listed in that national database (n = 42 456) in January 2013. Sample size calculation was performed based on population parameters. 22 With an accessible population of 42 456 DC e-mail addresses, a margin of error of 3%, a confidence level of 95%, and a response distribution of 50%, the calculated base sample size is 1041. As a result, the relatively large confidence level (95% as opposed to 90%) combined with the relatively small margin of error (3% as opposed to 5%) increased the investigators' level of accuracy and confidence that the sample statistic reflected the desired population parameters. 23 The e-mail letter of invitation included the title and purpose of the project, procedures for the anonymous and voluntary nature of the survey, and potential risks and benefits of participation. A reminder e-mail was sent out 10 days after the initial e-mail letter of invitation was dispatched. The inclusion criterion was defined as any licensed DC (at least 20 years old; with no limit on maximum age criteria) primary occupation involving the chiropractic profession in anyone of the following capacities: clinical, academic, administrative, and/or research. Non-DCs and DCs who were principally involved in work outside the realm of chiropractic were excluded from the study. Non–direct care DCs (ie, administrators, academics, and/or researchers) were not required to answer questions that referred to direct patient care.
Measurement of Burnout The Maslach Burnout Inventory–Human Services Survey (MBI-HSS) 15 has been subjected to numerous exploratory factor analyses, confirming the 3 components of burnout—EE, DP, and PA—and is often referred to as the “gold standard.” 24 The evidence reported in the literature 15 supports that MBI-HSS is a suitable measurement tool to assess burnout across a diversity of pro-
Williams and Zipp Burnout
fessions. More so, given the validity and reliability of the MBI-HSS that has been demonstrated in various populations of health professionals, it appears that the MBI-HSS provides a reasonable instrument for measuring burnout of DCs at this time.
Questionnaire The first part of the questionnaire (MBI-HSS) consisted of 22 Likert scale questions measuring the 3 aspects (EE, DP, PA) of burnout, which were subsequently categorized as the dependent variables of interest. Permission to use the MBI-HSS was obtained from Consulting Psychologists Press (http://www.mindgarden.com). The second part of questionnaire contained questions that were associated with chiropractic-specific stressors, as described in the literature. 7-10,25-27 Ethics approval for this study was obtained by Seton Hall University's Institutional Review Board in January 2013.
Statistical Analysis Means and SDs were calculated for the 3 MBI subscales. Three 1-sample t tests were conducted to assess if the MBIHSS subscales are significantly different from the health care norms. Occupations represented in the normative samples include 1101 medical workers (physicians, nurses) and are noted in the MBI manual. 13 The scores from DCs surveyed were compared with the 3 health care norms. The assumption of normality was assessed prior to analysis with Kolmogorov-Smirnov tests. Spearman correlations, independent-sample t tests, and 1-way analyses of variance (ANOVAs) were conducted to assess the interactions between EE, PA, and DP with the sociodemographic variables. Prior to analysis of the ANOVAs, Levene tests were conducted to assess the assumption of equality of variance. In the event that an ANOVA was significant, pairwise comparisons were run with a Bonferroni correction to determine which of the groups were significantly different from each other.
RESULTS Of the 1408 DCs who volunteered to participate in the study by accessing the survey, only data from 1162 DCs were analyzed and reported on in this study. The 246 surveys not analyzed were incomplete and thus excluded from the data analysis. Of that, 6.2% of the surveys returned indicated that the respondent was not currently in practice. As a result, the relative return rate of this study was 16.06%. In the social sciences, the typical rate of return on e-mail/ Web-based surveys is noted in the literature as between 11% and 15.4%. 28,29
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Table 1. Frequencies and Percentages for Participant Demographics Demographic Sex Female Male Age (y) 20-30 31-40 41-50 51-60 61-70 71+ Years in profession 0-5 6-10 11-15 16-20 20-25 25-30 31+ Marital status Married Widowed Divorced Separated Never married
n
%
206 943
18 82
61 220 309 387 148 24
5 19 27 34 13 2
88 127 197 137 169 176 255
8 11 17 12 15 15 22
925 9 108 13 94
81 1 9 1 8
Percentages may not total 100 due to rounding error.
Demographic Profile Frequencies and percentages for participant demographics (Table 1), work characteristics (Table 2), and chiropractic characteristics (Table 3) are provided. The percentage distribution of sex and the number of years in the profession found in this study were reflective of the current industry data. 30
Prevalence of Burnout Reliability was conducted on the 3 MBI subscales for this study. Reliability for EE was Cronbach α = .93. Reliability for PA was α = .76. Reliability for DP was α = .74. All reliabilities were above the .70 level, which represents an acceptable reliability. 31 Frequencies and percentages (Table 4) were calculated on the groupings of scores based on values provided by the MBI manual. 15 Based on the groupings, 21% (242) of the participants had high EE, 8% (94) had low PA, and 8% (98) had high DP. In total, only 20 participants (2%) had high burnout (high EE and DP, low PA), whereas 539 participants (46%) had low burnout (low EE and DP, high PA). The remaining 52% were categorized as mixed, which involved varying combinations of subscores values.
DC MBI vs Medical Norm MBI Values Three 1-sample t tests were conducted to compare the 3 MBI subscales to the norms based on the medicine group
Table 2. Frequencies and Percentages for Working Characteristics Characteristic Professional status Associate Independent contractor Sole practitioner Group practice Not a direct care provider Own practice/business Yes No Time dedicated to clinical care b25% 25%-50% 51%-75% N76% Time dedicated to administrative duties b25% 25%-50% 51%-75% N76% Hours worked per week b20 21-40 N40 Patients treated per day 0-10 11-20 21-30 31-40 41-50 N50 Patients treated per week 0-50 51-100 N100
n
%
57 53 761 232 46
5 5 66 20 4
977 121
89 11
46 177 428 447
4 16 39 41
553 432 72 41
50 39 7 4
60 666 372
6 61 34
130 333 298 145 81 110
12 30 27 13 7 10
241 440 417
22 40 38
Percentages may not total 100 due to rounding error.
(Table 5). These values are significantly lower than what is expressed in the medical, nursing, and physical therapy literature. 15,16,32,33
Factors Associated With DC Burnout Emotional exhaustion was significantly positively related to time dedicated to administrative duties (r = 0.25, P b .001) and hours worked per week (r = 0.15, P b .001), but was significantly negatively correlated with time dedicated to clinical care (r = − 0.15, P b .001). Personal accomplishment was significantly positively correlated with time dedicated to clinical care (r = 0.15, P b .001), but was significantly negatively correlated with time dedicated to administrative duties (r = − 0.22, P b .001). Depersonalization was significantly positively correlated with time dedicated to administrative duties (r = 0.17, P b .001). Independent-sample t tests were conducted for the dichotomous sociodemographic factors, whereas ANOVAs were conducted when there were more than 2 nominal categories on the EE, PA, and DP subscores. Results of the t
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Table 3. Frequencies and Percentages for Chiropractic Characteristics Characteristic Primary practice setting/type Acute Subacute Chronic Wellness Not direct care provider Primary reimbursement Workman compensation/Personal injury Cash-fee services Major medical Other Focus of chiropractic work Subluxation-based Musculoskeletal Focus of chiropractic college Subluxation-based Musculoskeletal Location of chiropractic college United States Canada International Have symptoms of burnout Yes No Dealing with insurance companies increases burnout Yes No Work-related injuries increase burnout Yes No Varying philosophical philosophies increases burnout Yes No Public perception increases burnout Yes No
n
%
377 279 216 228 44
33 24 19 20 4
125 315 641 63
11 28 56 6
185 839
18 82
296 729
29 71
1100 30 14
96 3 1
336 801
30 70
891 127
88 13
169 968
15 85
323 814
28 72
496 641
44 56
Percentages may not total 100 due to rounding error.
tests showed that PA (t1147 = 2.28, P = .023) and DP (t1147 = 3.42, P = .001) was related to sex. Women had higher PA scores and lower DP scores compared with men's PA and DP scores. Owning the business/practice was significantly related to DP (t1096 = 3.32, P = .001). Those who owned their business had significantly lower DP scores compared with those who did not. Emotional exhaustion (t1022 = 6.48, P = .001), PA (t1022 = 3.45, P = .001), and DP (t1022 = 4.16, P = .001) were also related to chiropractic focus. Those with a musculoskeletal focus had significantly higher EE and DP scores compared with those that focused on subluxation based. Those with a subluxation-based focus had significantly higher PA scores compared with those who were musculoskeletal. Having symptoms of burnout was found to be significantly related to EE (t1135 = 31.04, P = .001), PA (t1135 = 12.52, P = .001), and DP (t 1135 = 17.72, P = .001). Those who had symptoms of burnout had significantly higher EE and DP scores and significantly lower PA scores compared with those who did not have symptoms of burnout. Dealing
Table 4. Frequencies and Percentages of Subscale Categorizations Subscale
Mean
SD
EE Low Average High PA High Average Low DP Low Average High Burnout Low Mixed High
16.16
12.30
41.63
n
%
696 223 242
60 19 21
887 180 94
76 16 8
873 190 98
75 16 8
539 602 20
46 52 2
6.82
4.53
5.07
–
–
DP, depersonalization; EE, emotional exhaustion; PA, reduced personal accomplishment.
Table 5. Results for 1-sample t Tests for EE, PA, and DP Score
Test value
M
SD
t1160
P
EE PA DP
22.19 36.53 7.12
16.16 41.63 4.53
12.30 6.82 5.07
− 16.69 25.52 − 17.38
.001 .001 .001
DP, depersonalization; EE, emotional exhaustion; PA, reduced personal accomplishment.
with insurance companies increasing burnout was significantly related to EE (t1096 = 6.05, P = .001) and DP (t1096 = 3.32, P = .001). Those who said that it did increase burnout had significantly higher EE and DP scores. Having a work-related injury was significantly related to EE (t1135 = 8.30, P = .001), PA (t1135 = 4.05, P = .001), and DP scores (t1135 = 6.98, P = .001). Those who said that a work-related injury could increase their sense of burnout had significantly higher EE and DP scores and significantly lower PA scores compared with those who did not think that a work-related injury increased burnout. As per the potential unique causes of burnout for chiropractic professionals, those who thought that varying philosophical perspectives (straight vs mixer) within the chiropractic profession could increase burnout had significantly higher EE and DP scores and significantly lower PA scores compared with those who did not think so. In addition, those who thought that the public perception of chiropractic could increase burnout also had significantly higher EE and DP scores and significantly lower PA scores compared with those who did not think so. Analyses of variance were conducted to assess if the 3 MBI subscales were significantly different based on the nominal demographic variables. Many of the ANOVAs were very significant as revealed by their F values. By examining only the ANOVAs that were significant at the .01 level, the risk for type I error was reduced. In the event
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that an ANOVA was significant, pairwise comparisons were run with a Bonferroni correction to determine which of the comparisons were significant. Marital status was related to PA scores (F4,1144 = 2.73, P = .028); however, during pairwise comparisons (Bonferroni), no significant differences were found. Professional status was related to PA (F4,1144 = 3.86, P = .004) and DP (F4,1144 = 3.97, P = .003). No differences were found in the pairwise comparisons (Bonferroni) for PA, but associates had significantly higher DP scores compared with independent contractors, sole practitioners, and group practitioners. Practice setting was significantly related to EE (F4,1139 = 11.84, P = .001), PA (F4,1139 = 5.89, P = .001), and DP (F4,1139 = 4.72, P = .001). The DCs who predominantly provided “wellness care” to patients had significantly lower EE and DP scores than those DCs who primarily provided treatment to patients with acute, subacute, and chronic ailments. In addition, wellness care DCs had significantly higher PA scores than did DCs who treat patients with acute, subacute, and chronic conditions. Reimbursement type was significantly related to EE (F3,1140 = 17.60, P = .001), PA (F3,1140 = 11.98, P = .001), and DP (F3,1140 = 13.88, P = .001). Those who received workers' compensation had significantly higher EE scores compared with those who practiced in a cash-fee setting. Those who engaged in cash-fee reimbursement types had significantly lower EE scores compared with those who had major medical as their primary reimbursement type. Those who had workers' compensation as their primary reimbursement had significantly lower PA compared with those who practiced in a cash-fee and major medical reimbursement types. Those who had workers' compensation or other major medical third party as their primary reimbursement type had significantly higher DP compared with those who practiced in a cash-fee and major medical reimbursement types. Interestingly, location of college was significantly related to DP (F2,1141 = 8.65, P = .001). Those who attended international colleges had significantly higher DP scores compared with those who attended college in the United States and Canada. Surprisingly, college attended was also related to EE (F22,1019 = 2.30, P = .001) and DP (F22,1019 = 1.63, P = .034). Table 6 presents the means and SDs for all of the sociodemographic factors for EE, PA, and DP scores.
DISCUSSION This study's findings are largely consistent with the pilot findings 20 on 90 DCs in the northeastern region of the United States. In the current exploratory study, nearly 40% of the respondents recorded moderate (19%) to high (21%) levels of EE, whereas most respondents scored a high (76%) level of PA.
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The present study showed that DCs who spent more time dedicated to administrative duties and less time to clinical care had a greater tendency toward higher burnout subscores. In addition, those DCs who owned their business; worked primarily in an acute, subacute, and/or chronic care environment; and depended on workers' compensation/personal injury as a primary source of payment for services render also had predisposition toward higher burnout subscores. Adding to these challenges, there were other chiropractic-specific variables that appeared to have a negative effect on burnout subscores including the following: having a musculoskeletal-focused practice (as opposed to subluxation based), having a work-related injury (perhaps from the physical demands performing manual therapy), witnessing the opposing philosophical perspectives within the chiropractic profession, and dealing with the inconsistent public opinion of the chiropractic profession. Despite the present study's observed lower EE among DCs, the presence of high EE observed in other similar professions raises the relevance of EE as a concern for DCs because it may ultimately increase the incidence of burnout (as per Maslach Tripartite theory), 15 attrition, and unprofessionalism and have a negative impact on the patientpractitioner relationship. 34,35 Emotional exhaustion is considered to be the core element of burnout, 21 and according to Maslach and Jackson, 36 the EE subscale primarily reflects the organizational and the social climate of the work environment. Interestingly, the DCs in this study showed moderate levels of EE when questioned about organizational (practice setting/type, reimbursement/regulation, therapeutic focus, and physical demands of practice) and social stressors (perception, public opinion, and varying philosophical views) that appear to hamper the profession. Given the negative consequences of high EE levels on individual health and job performance, 16,37 the present study reveals that creating conditions to prevent or minimize EE among DCs is important not only for DCs but also for the clients they serve and the organizations in which they are employed. Overall, this sample of DCs reported lower EE and DP scores and higher PA scores than did their medical, 16,38-43 nursing, 44-48 physical therapy, 33,49-51 occupational therapy, 33,49,52,53 and dentistry 35,54,55 colleagues who have been evaluated using the MBI-HSS. As a result, this group of DCs fared more favorably than did the subset of other health professionals on all 3 dimensions of burnout. Therefore, the findings from this study may serve as a catalyst for further conversation (intraprofessional and interprofessional) on the prevention and/or management of burnout amid similar professions. In the literature, age is the demographic variable that is most consistently correlated with burnout, with higher levels seen among workers younger than 30 to 40
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Table 6. Means and SDs for EE, PA, and DP Scores by Nominal Sociodemographic Factors EE Sociodemographic Sex Female Male Marital status Married Widowed Divorced Separated Never married Professional status Associate Independent contractor Sole practitioner Group practice Not direct care provider Own practice/business Yes No Associate DC present Yes No Primary practice setting Acute Subacute Chronic Wellness Not direct care Primary reimbursement Workman compensation/personal injury Cash-fee services Major medical Other Chiropractic focus Subluxation-based Musculoskeletal College focus Subluxation-based Musculoskeletal Location United States Canada International Have burnout Yes No Dealing with insurance increases burnout Yes No Work-related injury increases burnout Yes No Varying philosophical views increases burnout Yes No Public perception increases burnout Yes No
PA
Mean
SD
Mean
15.42 16.33
11.32 12.50
42.65 41.45
16.08 12.67 16.31 20.62 16.55
12.25 11.78 12.09 16.27 12.55
18.93 15.08 16.25 15.90 14.00
DP SD
Mean
SD
6.12 6.94
3.44 4.77
4.15 5.24
41.51 42.78 43.31 44.46 40.77
6.94 6.53 5.68 4.75 6.74
4.56 4.11 4.09 5.92 4.59
5.18 5.84 4.52 6.30 4.58
13.12 11.86 12.38 12.21 10.52
40.18 39.60 41.82 42.41 39.52
7.73 10.13 6.58 5.73 8.75
6.88 4.00 4.37 4.39 5.61
5.64 3.83 4.97 5.32 5.67
16.04 18.18
12.28 12.99
41.84 41.00
6.65 7.27
4.32 5.93
4.97 5.60
15.58 16.44
12.60 12.32
41.75 41.75
7.15 6.62
4.43 4.51
5.37 4.99
17.94 17.62 16.69 11.67 12.89
12.84 12.66 11.95 10.45 10.03
41.31 41.49 40.81 43.52 40.30
7.20 6.92 7.12 5.19 7.35
4.81 4.77 5.02 3.25 5.11
5.12 5.34 5.47 4.13 5.04
20.32 12.59 17.41 13.38
13.02 11.18 12.41 10.37
38.52 42.59 41.93 40.56
7.46 6.31 6.77 6.74
6.57 3.29 4.71 5.11
5.86 4.36 5.12 5.12
10.94 17.33
10.37 12.48
43.22 41.36
5.67 6.81
3.18 4.90
4.38 5.22
15.20 16.55
12.80 12.18
42.00 41.58
6.95 6.53
4.59 4.59
5.42 4.99
16.19 13.87 20.64
12.27 10.95 17.43
41.67 41.47 41.21
6.79 8.44 6.02
4.51 3.30 9.86
5.06 2.97 7.95
29.10 10.79
11.49 7.84
38.07 43.23
7.90 5.56
8.19 3.00
6.44 3.39
17.06 10.07
12.41 10.45
41.78 41.60
6.42 7.60
4.77 3.17
5.13 4.79
23.26 14.97
13.88 11.62
39.78 42.05
7.89 6.49
7.00 4.10
6.37 4.71
21.02 14.29
12.86 11.58
39.99 42.39
7.61 6.26
6.58 3.72
6.18 4.33
21.36 12.21
12.69 10.43
40.22 42.86
7.28 6.09
6.31 3.15
5.87 3.88
DC, doctor of chiropractic; DP, depersonalization; EE, emotional exhaustion; PA, reduced personal accomplishment.
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years. 32,37 In the present study, with 76% of respondents being older than 40 years, it is plausible that the underrepresentation of younger DCs may have resulted in lower levels of reported burnout on EE and DP and/or inability to see the true effect of age on burnout. However, the moderate association noted between age and subscale scores is consistent with several studies of physical and occupational therapists. 16,49,51,52,56 Maslach and Jackson 57 hypothesized that age reflects more than just the length of time on the job. With increased age, people tend to demonstrate more stability and maturity, have a more balanced perspective on life, and are less prone to excesses of burnout. In the current study, it was shown that EE and DP were significantly negatively correlated with age, such that as age increased, EE and DP tended to decrease. It was encouraging to see that longer durations in practice (experience) were associated with lower levels of EE—a finding similar to those reported by previous authors. 56,58 In the current study, as DC practice experience increased, EE tended to decrease. These finding are further supported by previous studies that found higher levels of EE and DP, as measured by MBI-HSS, in more recent graduates than those who had a longer work history. 51,56,59 In fact, Maslach and Jackson 37 suggest that age is confounded with work experience, so burnout appears to be more of a risk earlier in one's career. The reasons for such an interpretation have not been studied but should be viewed with caution because of the problem of survival bias—that is, those who burn out early in their careers are likely to quit their jobs, leaving behind the survivors who consequently exhibit lower levels of burnout. 37 The demographic variable of sex has not been a strong predictor of burnout (despite some arguments that burnout is more of a female experience) 37; however, it does play a significant role in the perception and origin of stress. 58 In the current study, female DCs had higher PA scores and lower DP scores compared with men's PA and DP scores; however, these results may also reflect the confounding of sex with occupation (eg, DCs are more likely to be male). As would be expected, a large percentage (89%) of the DCs surveyed indicated that they owned their business/ practice. Those DCs who did own their business had significantly lower DP scores compared with those who did not. Being entrepreneurs, the typical working conditions and responsibilities of DCs are likely to differ from that of other helping professionals whose primary care duties are traditionally hospital or clinic based. Te Brake et al 60 argue that certain specific aspects of entrepreneur-like occupations are reflective in deviating responses to the MBI. However, the impact of these responsibilities did not seem to have a major influence on this group of DCs' overall DP scores, suggesting that despite the hardships that may be associated with operating a business, DCs seemed to avoid
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distancing themselves from those receiving care, their clients. It was expected that the primary reimbursement type, practice setting, and therapeutic focus would affect burnout levels. Doctors of chiropractic who primarily worked in wellness-focused facilities, were subluxation based, and relied on cash-for-services rendered had significantly lower EE and DP scores and higher PA scores compared with those practitioners who worked in acute, subacute, and/or chronic setting, with a musculoskeletal focus, and who relied on either workers compensation/personal injury or major medical as the primary source of reimbursement for services rendered. This relationship is perhaps the combined end product of caring for a healthier population of clients (as opposed to ill) and the elimination of stressors that tend to coexist with the administrative challenges of billing and collections. Upon further reflection, another possible reason for this symbiotic relationship could be a result of the intrinsic uncertainties about reimbursement, which is ultimately influenced by changes in the external environment such as changes in the economy, managed care regulations, and the social climate. However, it should be duly noted and cited as a limitation that providing only 2 options (subluxation based/straight vs musculoskeletal/mixer) for focus of chiropractic work question may be argued as being limited. As such, present-day chiropractic has evolved to tolerate several other contentious and polar aspects of practice such as patient-centered vs self (doctor)-centered practice, evidence-based vs belief-based practice, holistic-wellness vs symptom-relief practice, marketing-based practice management vs referral-based practice, and separate and distinct profession vs integrative, health care team profession, among many others. An a priori assertion was proposed, which predicted a correlation between burnout subscales and the effect of legal scope of practice (restrictive or expansive) and the graduating college's academic focus (beyond accreditation mandates). Using the literature compiled from the American Chiropractic Association Web sites, the Chiropractic Resources Organization (http://www.chiro.org/ main/), the 19 chiropractic colleges located in the United States were categorized as either a straight/objective or mixer/reform by the principal investigator based on a sample of contemporary chiropractic materials. 5,10,18,19 For the first assumption, the 1-way ANOVA showed no statistical difference, thereby confirming that levels of burnout do not differ per geographical state. However, because there was one grouping variable that included all the states (separated), it was unlikely that any statistical differences would be found to begin with. For the second assumption, statistically significant but weak differences emerged, but there did not appear to be much of a difference of overall burnout values.
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Self-perception and/or identifying with the operational definition of burnout was notably the strongest association witnessed in this study. There was a large statistical difference between those DCs who acknowledged they had burnout and those who noted they did not have burnout. Here, respondents were first provided with Maslach's definition of burnout 15,37 and then asked to identify if they could identify with having symptoms of burnout presently. Those DCs who had symptoms of burnout (as per Maslach's definition) had significantly higher EE and DP scores and significantly lower PA scores compared with those who did not have symptoms of burnout. Among many possible explanations (extraneous and confounding), this relationship may support the notion of construct validity and the application of MBI-HSS 61 to the chiropractic profession. Perhaps the most compelling aspects of the results were in the unique DC stressors category. Doctors of chiropractic reported negative tendencies toward the varying philosophical perspectives within the profession and the negative public opinion of the chiropractic profession. These findings support the theoretical rational proposed, which merges job demands-resources model 62 and Maslach Tripartite theory 15 and thus warrants further investigation into their effects on job stress, attrition, and burnout within the chiropractic profession.
Limitations and Future Studies Several limitations must be kept in mind concerning the implications based on the results of this study. First, that this study was exploratory in nature and used a convenience sample of DCs must be recognized. In addition, the crosssectional nature of this study means that causal relation cannot be established. The sampling methodology involved a random selection of DCs from an e-mail directory; therefore, those DCs who were not included in the database and/or those who may have left the profession as a result of burnout would not have been invited to participate in the study. In fact, approximately 6% of the surveys returned indicated that the respondents were not currently in practice.
CONCLUSION The findings from this study indicate that the prevalence of burnout among the group of DCs who responded to the survey is remarkably low, and this group of DCs presented with lower levels of burnout compared with other health care professionals. The results from this present study begin to fill the void that exists within the chiropractic literature in relation to understanding the prevalence of burnout and its potential impact on the profession.
Williams and Zipp Burnout
Practical Applications • Overall burnout scores for DCs were significantly lower than health care norms. • Of the independent variables examined, statistically significant relationships were found between burnout subscales and the effects of sex, time dedicated to clinical care and administrative duties, source of reimbursement, the type of practice setting, the nature of practitioners' therapeutic focus, the location of chiropractic college, self-perception of burnout, the of effect of suffering from a work-related injury, the varying chiropractic philosophical perspectives, and the public's opinion of chiropractic. • Although DC in the United States had lower levels of burnout compared with other health care professionals, higher levels of EE remain workplace issues for this professional group.
FUNDING SOURCES
AND
POTENTIAL CONFLICTS
OF INTEREST
No funding sources or conflicts of interest were reported for this study.
CONTRIBUTORSHIP Concept development (provided idea for the research): SW, GZ. Design (planned the methods to generate the results): SW. Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): SW, GZ. Data collection/processing (responsible for experiments, patient management, organization, or reporting data): SW. Analysis/interpretation (responsible for statistical analysis, evaluation, and presentation of the results): SW Literature search (performed the literature search): SW Writing (responsible for writing a substantive part of the manuscript): SW. Critical review (revised manuscript for intellectual content, this does not relate to spelling and grammar checking): SW.
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25. Copper R, McKee HJ. Chiropractic in the United States: trends and issues. Milbank Q 2003;81:107-38. 26. Foreman SM, Stahl MJ. Chiropractors disciplined by a state chiropractic board and a comparison with disciplined medical physicians. J Manipulative Physiol Ther 2004;27: 472-7. 27. Editoral Staff. Gallup poll: Americans have low opinion of chiropractors; honesty and ethics. Dynamic Chiropr 2007; 25. 28. Blumberg SJ, Luke JV. Wireless substitution: early release of estimates from the National Health Interview Survey, JulyDecember 2008. http://www.cdc.gov/nchs/data/nhis/earlyrelease/ wireless200905.pdf. National Center for Health Statistics. Published May 6, 2009. 29. Keeter S, Kennedy C, Clark A, Tompson T, Mokrzycki M. What's missing from national landline RDD surveys? The impact of the growing cell-only population. Public Opin Q 2007;71:772-92. 30. Christensen MG, Kollasch MW, Hyland JK. Practice of chiropractic: a project report, survey analysis, and summary of the practice of chiropractic within the United States. Greeley (Colo): National Board of Chiropractic Examiners; 2010. 31. George D, Mallery P. SPSS for Windows step by step: a simple guide and reference 11.0 update. 4th ed. Boston (Mass): Allyn and Bacon; 2003. 32. Gingras J, de Jonge LA, Purdy N. Prevalence of dietitian burnout. J Hum Nutr Diet 2010;23:238-43. 33. Balogun JA, Titiloye V, Balogun A, Oyeyemi A, Katz J. Prevalence and determinants of burnout among physical and occupational therapists. J Allied Health 2002;31:131-9. 34. Munn-Giddling C, Hart C, Ramon S. A participatory approach to the promotion of well-being in the workplace: lesson from empirical research. Int Rev Psychiatr 2005;17: 409-17. 35. Te Brake H, Bouman AM, Gorter R, Hoogstraten J, Eijkman M. Professional burnout and work engagement among dentists. Eur J Oral Sci 2007;115:180-5. 36. Maslach C, Jackson SE. Burnout in organization settings. Applied Social Psychology Annual 1984;5:133-53. 37. Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol 2001;52:397-422. 38. Ybema JF, Evers MS, van Scheppingen AR. A longitudinal study on the effects of health policy in organizations on job satisfaction, burnout, and sickness absence. J Occup Environ Med 2011;53:1251-7. 39. Dyrbye LN, Thomas MR, Massie FS, et al. Burnout and suicidal ideation among U.S. medical students. Ann Intern Med 2008;149:334-41. 40. Grembowski D, Paschane D, Diehr P, Katon W, Martin D, Patrick DL. Managed care, physician job satisfaction, and the quality of primary care. J Gen Intern Med 2005;20: 271-7. 41. Edwards N, Kornacki MJ, Silversin J. Unhappy doctors: what are the causes and what can be done? BMJ 2002;324: 835-8. 42. Linzer M, Visser MR, Oort FJ, et al. Predicting and preventing physician burnout: results from the United States and the Netherlands. Am J Med 2001;111:170-5. 43. Maslach C, Jackson SE. The measurement of experienced burnout. J Occup Behav 1981;2:99-113. 44. Akhtar S, Lee JS. Job burnout: toward an integration of two dominant resource-based models. Psychol Rep 2010;107: 193-208. 45. Dickinson T, Wright KM. Stress and burnout in forensic mental health nursing: a literature review. Br J Nurs 2008;17: 82-7.
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46. Ilhan MN, Durukan E, Taner E, Maral I, Bumin MA. Burnout and its correlates among nursing staff: questionnaire survey. J Adv Nurs 2008;61:100-6. 47. Janssen PP, Jonge JD, Bakker AB. Specific determinants of intrinsic work motivation, burnout and turnover intentions: a study among nurses. J Adv Nurs 1999;29:1360-9. 48. Piko BF. Burnout, role conflict, job satisfaction and psychosocial health among Hungarian health care staff: a questionnaire survey. Int J Nurs Stud 2006;43:311-8. 49. Schlenz KC, Guthrie MR, Dudgeon B. Burnout in occupational therapists and physical therapists working in head injury rehabilitation. Am J Occup Ther 1995;49:986-93. 50. Schuster ND, Nelson DL, Quisling C. Burnout among physical therapists. Phys Ther 1984;64:299-303. 51. Donohoe E, Nawawi A, Wilker L, Schindler T, Jette DU. Factors associated with burnout of physical therapists in Massachusetts rehabilitation hospitals. Phys Ther. 1993;73: 750, 6; [discussion 756–61]. 52. Rogers JC, Dodson SC. Burnout in occupational therapists. Am J Occup Ther 1988;42:787-92. 53. Painter J, Akroyd D, Elliot S, Adam RD. Burnout among occupational therapists. Occup Ther Health Care 2003;17: 63-78. 54. Osborne D, Croucher R. Levels of burnout in general dental practitioners in the south-east of England. Br Dent J 1994;177: 372-7.
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55. Humphris G. A review of burnout in dentists. Dent Update 1998;25:392-6. 56. Wandling BJ, Smith BS. Burnout in orthopaedic physical therapists. J Orthop Sports Phys Ther 1997;26:124-30. 57. Maslach C, Jackson SE. Burnout in health professions: a social psychological analysis. In: Sanders G, Suls J, editors. Social psychology of health and illness. Hillsdale (NJ): Erlbaum; 1982. p. 227-51. 58. Kumar S, Fischer J, Robinson E, Hatcher S, Bhagat RN. Burnout and job satisfaction in New Zealand psychiatrists: a national study. Int J Soc Psychiatry 2007;53:306-16. 59. Lindsay R, Hanson L, Taylor M, McBurney H. Workplace stressors experienced by physiotherapists working in regional public hospitals. Austr J Rural Health 2008;16:194-200. 60. Te Brake JH, Bouman AM, Gorter RC, Hoogstraten J, Eijkman MA. Using the Maslach Burnout Inventory among dentists: burnout measurement and trends. Community Dent Oral Epidemiol 2008;36:69-75. 61. Montero-Marin J, Skapinakis P, Araya R, Gili M, GarciaCampayo J. Towards a brief definition of burnout syndrome by subtypes: development of the “burnout clinical subtypes questionnaire” (BCSQ-12). Health Qual Life Outcomes. 2011;9:74. 62. Demerouti E, Bakker AB, Nachreiner F, Schaufeli WB. The job demands-resources model of burnout. J Appl Psychol 2001;86:499-512.
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OF
BURNOUT
Shawn P. Williams, DC, PhD, a and Genevieve P. Zipp, PT, EdD b
ABSTRACT Objective: The purpose of this study was to establish the frequency of burnout among doctors of chiropractic in the United States. Methods: Using a nonprobability convenience sampling methodology, we e-mailed the Maslach Burnout Inventory– Human Services Survey and a sociodemographic questionnaire to a randomized sample of licensed doctors of chiropractic (n = 8000). Results: The survey return rate was 16.06%. Twenty-one percent of the participants had high emotional exhaustion (EE), 8% had low personal accomplishment, and 8% had high depersonalization. Discussion: Significant differences (P b .001) were found in the level of EE, depersonalization, and personal accomplishment as a function of sex, time dedicated to clinical care and administrative duties, source of reimbursement, the type of practice setting, the nature of practitioners' therapeutic focus, the location of chiropractic college, self-perception of burnout, the effect of suffering from a work-related injury, the varying chiropractic philosophical perspectives, and the public's opinion of chiropractic. Conclusion: Although doctors of chiropractic in the United States who responded to the survey had a relatively low frequency of burnout, higher levels of EE remain workplace issues for this professional group. (J Manipulative Physiol Ther 2014;37:180-189) Key Indexing Terms: Prevalence; Burnout, Professional; Chiropractic
ainstream health care and governmental organizations such as the World Health Organization consider chiropractic to be complementary and alternative medicine. 1 The chiropractic profession is the largest complementary and alternative medicine profession 2 and one of the largest licensed health care professions in the United States. 3 Reports from chiropractic governing bodies, trade magazines, and research proceedings suggest that although the practice of chiropractic can be remarkably meaningful and personally gratifying, it is also arduous and stressful. 4-10 Researchers investigating burnout agree that health care professionals (allopathic physicians, nurses, and various rehabilitation therapists) have a high potential for developing stress and consequently burnout. 11-13 Burnout is a “psychological syndrome” 14,15 that entails a feeling of
M
a
Assistant Professor, Department of Health Professions, CUNY–York College, Jamaica, NY. b Professor, Graduate Programs in Health Science, Seton Hall University, South Orange, NJ. Submit requests for reprints to. Shawn P. Williams, DC, PhD, Assistant Professor, 94-20 Guy R. Brewer Blvd, SCI 115, Jamaica, NY 11451 (e-mail: [email protected]). Paper submitted August 14, 2013; in revised form November 16, 2013; accepted November 20, 2013. 0161-4754/$36.00 Copyright © 2014 by National University of Health Sciences. http://dx.doi.org/10.1016/j.jmpt.2013.12.008
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being emotionally overextended and exhausted by one's work (emotional exhaustion [EE]), a negative and/or cynical attitude that provokes impersonal feelings toward one's clients (depersonalization [DP]), and a sense that one is achieving little—hence having low productivity (reduced personal accomplishment [PA]). Because doctors of chiropractic (DCs) face many of the same stressors and/or challenges as other health care providers with decreased reimbursement, changing patient payer types, changing patient and payer expectations, and diminished profit margins, 16-19 they also face unique set of profession-specific stressors such as philosophical dissonances, unconstructive public perception, increased market competition (both internally and externally), a relatively high prevalence of work-related injuries and a high student loan default rate. 5,8-10 Common challenges within the health care arena, combined with the noted chiropracticspecific stressors and the chronic work-related stressors of caring for individuals, may pose a hazard to the DC at risk for developing burnout. Results from a recent study 20 support the abovedescribed notion that DCs face unique profession-specific stressors (such as the professions' public perception and philosophical inconsistencies) that appear to have an association with their subsequent burnout indices. Although the study (n = 90) was limited to the northeastern region of the United States, the moderate levels of EE (the core
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element of burnout) 21 revealed in this cohort support the need to further explore the regional differences that may contribute to the stressors responsible for burnout in DCs across the United Sates. A larger study might help identify precipitating factors (ie, academic preparation and scope of practice) of professional burnout and thus help generate a dialogue on improving the quality of professional life for DCs. Therefore, the purpose of this study was to establish the frequency of burnout among DCs in the United States.
METHODS This study was exploratory descriptive in nature and involved the use of cross-sectional data collection as a means of understanding the prevalence of burnout among DCs. An e-mail letter of invitation with a hyperlink to an online version of the survey was sent to the randomized sample of 8000 DCs (as provided by MPA Media; http://www. mpamedia.com/). As such, the accessible population was defined as any DCs with an e-mail address listed in that national database (n = 42 456) in January 2013. Sample size calculation was performed based on population parameters. 22 With an accessible population of 42 456 DC e-mail addresses, a margin of error of 3%, a confidence level of 95%, and a response distribution of 50%, the calculated base sample size is 1041. As a result, the relatively large confidence level (95% as opposed to 90%) combined with the relatively small margin of error (3% as opposed to 5%) increased the investigators' level of accuracy and confidence that the sample statistic reflected the desired population parameters. 23 The e-mail letter of invitation included the title and purpose of the project, procedures for the anonymous and voluntary nature of the survey, and potential risks and benefits of participation. A reminder e-mail was sent out 10 days after the initial e-mail letter of invitation was dispatched. The inclusion criterion was defined as any licensed DC (at least 20 years old; with no limit on maximum age criteria) primary occupation involving the chiropractic profession in anyone of the following capacities: clinical, academic, administrative, and/or research. Non-DCs and DCs who were principally involved in work outside the realm of chiropractic were excluded from the study. Non–direct care DCs (ie, administrators, academics, and/or researchers) were not required to answer questions that referred to direct patient care.
Measurement of Burnout The Maslach Burnout Inventory–Human Services Survey (MBI-HSS) 15 has been subjected to numerous exploratory factor analyses, confirming the 3 components of burnout—EE, DP, and PA—and is often referred to as the “gold standard.” 24 The evidence reported in the literature 15 supports that MBI-HSS is a suitable measurement tool to assess burnout across a diversity of pro-
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fessions. More so, given the validity and reliability of the MBI-HSS that has been demonstrated in various populations of health professionals, it appears that the MBI-HSS provides a reasonable instrument for measuring burnout of DCs at this time.
Questionnaire The first part of the questionnaire (MBI-HSS) consisted of 22 Likert scale questions measuring the 3 aspects (EE, DP, PA) of burnout, which were subsequently categorized as the dependent variables of interest. Permission to use the MBI-HSS was obtained from Consulting Psychologists Press (http://www.mindgarden.com). The second part of questionnaire contained questions that were associated with chiropractic-specific stressors, as described in the literature. 7-10,25-27 Ethics approval for this study was obtained by Seton Hall University's Institutional Review Board in January 2013.
Statistical Analysis Means and SDs were calculated for the 3 MBI subscales. Three 1-sample t tests were conducted to assess if the MBIHSS subscales are significantly different from the health care norms. Occupations represented in the normative samples include 1101 medical workers (physicians, nurses) and are noted in the MBI manual. 13 The scores from DCs surveyed were compared with the 3 health care norms. The assumption of normality was assessed prior to analysis with Kolmogorov-Smirnov tests. Spearman correlations, independent-sample t tests, and 1-way analyses of variance (ANOVAs) were conducted to assess the interactions between EE, PA, and DP with the sociodemographic variables. Prior to analysis of the ANOVAs, Levene tests were conducted to assess the assumption of equality of variance. In the event that an ANOVA was significant, pairwise comparisons were run with a Bonferroni correction to determine which of the groups were significantly different from each other.
RESULTS Of the 1408 DCs who volunteered to participate in the study by accessing the survey, only data from 1162 DCs were analyzed and reported on in this study. The 246 surveys not analyzed were incomplete and thus excluded from the data analysis. Of that, 6.2% of the surveys returned indicated that the respondent was not currently in practice. As a result, the relative return rate of this study was 16.06%. In the social sciences, the typical rate of return on e-mail/ Web-based surveys is noted in the literature as between 11% and 15.4%. 28,29
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Table 1. Frequencies and Percentages for Participant Demographics Demographic Sex Female Male Age (y) 20-30 31-40 41-50 51-60 61-70 71+ Years in profession 0-5 6-10 11-15 16-20 20-25 25-30 31+ Marital status Married Widowed Divorced Separated Never married
n
%
206 943
18 82
61 220 309 387 148 24
5 19 27 34 13 2
88 127 197 137 169 176 255
8 11 17 12 15 15 22
925 9 108 13 94
81 1 9 1 8
Percentages may not total 100 due to rounding error.
Demographic Profile Frequencies and percentages for participant demographics (Table 1), work characteristics (Table 2), and chiropractic characteristics (Table 3) are provided. The percentage distribution of sex and the number of years in the profession found in this study were reflective of the current industry data. 30
Prevalence of Burnout Reliability was conducted on the 3 MBI subscales for this study. Reliability for EE was Cronbach α = .93. Reliability for PA was α = .76. Reliability for DP was α = .74. All reliabilities were above the .70 level, which represents an acceptable reliability. 31 Frequencies and percentages (Table 4) were calculated on the groupings of scores based on values provided by the MBI manual. 15 Based on the groupings, 21% (242) of the participants had high EE, 8% (94) had low PA, and 8% (98) had high DP. In total, only 20 participants (2%) had high burnout (high EE and DP, low PA), whereas 539 participants (46%) had low burnout (low EE and DP, high PA). The remaining 52% were categorized as mixed, which involved varying combinations of subscores values.
DC MBI vs Medical Norm MBI Values Three 1-sample t tests were conducted to compare the 3 MBI subscales to the norms based on the medicine group
Table 2. Frequencies and Percentages for Working Characteristics Characteristic Professional status Associate Independent contractor Sole practitioner Group practice Not a direct care provider Own practice/business Yes No Time dedicated to clinical care b25% 25%-50% 51%-75% N76% Time dedicated to administrative duties b25% 25%-50% 51%-75% N76% Hours worked per week b20 21-40 N40 Patients treated per day 0-10 11-20 21-30 31-40 41-50 N50 Patients treated per week 0-50 51-100 N100
n
%
57 53 761 232 46
5 5 66 20 4
977 121
89 11
46 177 428 447
4 16 39 41
553 432 72 41
50 39 7 4
60 666 372
6 61 34
130 333 298 145 81 110
12 30 27 13 7 10
241 440 417
22 40 38
Percentages may not total 100 due to rounding error.
(Table 5). These values are significantly lower than what is expressed in the medical, nursing, and physical therapy literature. 15,16,32,33
Factors Associated With DC Burnout Emotional exhaustion was significantly positively related to time dedicated to administrative duties (r = 0.25, P b .001) and hours worked per week (r = 0.15, P b .001), but was significantly negatively correlated with time dedicated to clinical care (r = − 0.15, P b .001). Personal accomplishment was significantly positively correlated with time dedicated to clinical care (r = 0.15, P b .001), but was significantly negatively correlated with time dedicated to administrative duties (r = − 0.22, P b .001). Depersonalization was significantly positively correlated with time dedicated to administrative duties (r = 0.17, P b .001). Independent-sample t tests were conducted for the dichotomous sociodemographic factors, whereas ANOVAs were conducted when there were more than 2 nominal categories on the EE, PA, and DP subscores. Results of the t
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Table 3. Frequencies and Percentages for Chiropractic Characteristics Characteristic Primary practice setting/type Acute Subacute Chronic Wellness Not direct care provider Primary reimbursement Workman compensation/Personal injury Cash-fee services Major medical Other Focus of chiropractic work Subluxation-based Musculoskeletal Focus of chiropractic college Subluxation-based Musculoskeletal Location of chiropractic college United States Canada International Have symptoms of burnout Yes No Dealing with insurance companies increases burnout Yes No Work-related injuries increase burnout Yes No Varying philosophical philosophies increases burnout Yes No Public perception increases burnout Yes No
n
%
377 279 216 228 44
33 24 19 20 4
125 315 641 63
11 28 56 6
185 839
18 82
296 729
29 71
1100 30 14
96 3 1
336 801
30 70
891 127
88 13
169 968
15 85
323 814
28 72
496 641
44 56
Percentages may not total 100 due to rounding error.
tests showed that PA (t1147 = 2.28, P = .023) and DP (t1147 = 3.42, P = .001) was related to sex. Women had higher PA scores and lower DP scores compared with men's PA and DP scores. Owning the business/practice was significantly related to DP (t1096 = 3.32, P = .001). Those who owned their business had significantly lower DP scores compared with those who did not. Emotional exhaustion (t1022 = 6.48, P = .001), PA (t1022 = 3.45, P = .001), and DP (t1022 = 4.16, P = .001) were also related to chiropractic focus. Those with a musculoskeletal focus had significantly higher EE and DP scores compared with those that focused on subluxation based. Those with a subluxation-based focus had significantly higher PA scores compared with those who were musculoskeletal. Having symptoms of burnout was found to be significantly related to EE (t1135 = 31.04, P = .001), PA (t1135 = 12.52, P = .001), and DP (t 1135 = 17.72, P = .001). Those who had symptoms of burnout had significantly higher EE and DP scores and significantly lower PA scores compared with those who did not have symptoms of burnout. Dealing
Table 4. Frequencies and Percentages of Subscale Categorizations Subscale
Mean
SD
EE Low Average High PA High Average Low DP Low Average High Burnout Low Mixed High
16.16
12.30
41.63
n
%
696 223 242
60 19 21
887 180 94
76 16 8
873 190 98
75 16 8
539 602 20
46 52 2
6.82
4.53
5.07
–
–
DP, depersonalization; EE, emotional exhaustion; PA, reduced personal accomplishment.
Table 5. Results for 1-sample t Tests for EE, PA, and DP Score
Test value
M
SD
t1160
P
EE PA DP
22.19 36.53 7.12
16.16 41.63 4.53
12.30 6.82 5.07
− 16.69 25.52 − 17.38
.001 .001 .001
DP, depersonalization; EE, emotional exhaustion; PA, reduced personal accomplishment.
with insurance companies increasing burnout was significantly related to EE (t1096 = 6.05, P = .001) and DP (t1096 = 3.32, P = .001). Those who said that it did increase burnout had significantly higher EE and DP scores. Having a work-related injury was significantly related to EE (t1135 = 8.30, P = .001), PA (t1135 = 4.05, P = .001), and DP scores (t1135 = 6.98, P = .001). Those who said that a work-related injury could increase their sense of burnout had significantly higher EE and DP scores and significantly lower PA scores compared with those who did not think that a work-related injury increased burnout. As per the potential unique causes of burnout for chiropractic professionals, those who thought that varying philosophical perspectives (straight vs mixer) within the chiropractic profession could increase burnout had significantly higher EE and DP scores and significantly lower PA scores compared with those who did not think so. In addition, those who thought that the public perception of chiropractic could increase burnout also had significantly higher EE and DP scores and significantly lower PA scores compared with those who did not think so. Analyses of variance were conducted to assess if the 3 MBI subscales were significantly different based on the nominal demographic variables. Many of the ANOVAs were very significant as revealed by their F values. By examining only the ANOVAs that were significant at the .01 level, the risk for type I error was reduced. In the event
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that an ANOVA was significant, pairwise comparisons were run with a Bonferroni correction to determine which of the comparisons were significant. Marital status was related to PA scores (F4,1144 = 2.73, P = .028); however, during pairwise comparisons (Bonferroni), no significant differences were found. Professional status was related to PA (F4,1144 = 3.86, P = .004) and DP (F4,1144 = 3.97, P = .003). No differences were found in the pairwise comparisons (Bonferroni) for PA, but associates had significantly higher DP scores compared with independent contractors, sole practitioners, and group practitioners. Practice setting was significantly related to EE (F4,1139 = 11.84, P = .001), PA (F4,1139 = 5.89, P = .001), and DP (F4,1139 = 4.72, P = .001). The DCs who predominantly provided “wellness care” to patients had significantly lower EE and DP scores than those DCs who primarily provided treatment to patients with acute, subacute, and chronic ailments. In addition, wellness care DCs had significantly higher PA scores than did DCs who treat patients with acute, subacute, and chronic conditions. Reimbursement type was significantly related to EE (F3,1140 = 17.60, P = .001), PA (F3,1140 = 11.98, P = .001), and DP (F3,1140 = 13.88, P = .001). Those who received workers' compensation had significantly higher EE scores compared with those who practiced in a cash-fee setting. Those who engaged in cash-fee reimbursement types had significantly lower EE scores compared with those who had major medical as their primary reimbursement type. Those who had workers' compensation as their primary reimbursement had significantly lower PA compared with those who practiced in a cash-fee and major medical reimbursement types. Those who had workers' compensation or other major medical third party as their primary reimbursement type had significantly higher DP compared with those who practiced in a cash-fee and major medical reimbursement types. Interestingly, location of college was significantly related to DP (F2,1141 = 8.65, P = .001). Those who attended international colleges had significantly higher DP scores compared with those who attended college in the United States and Canada. Surprisingly, college attended was also related to EE (F22,1019 = 2.30, P = .001) and DP (F22,1019 = 1.63, P = .034). Table 6 presents the means and SDs for all of the sociodemographic factors for EE, PA, and DP scores.
DISCUSSION This study's findings are largely consistent with the pilot findings 20 on 90 DCs in the northeastern region of the United States. In the current exploratory study, nearly 40% of the respondents recorded moderate (19%) to high (21%) levels of EE, whereas most respondents scored a high (76%) level of PA.
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The present study showed that DCs who spent more time dedicated to administrative duties and less time to clinical care had a greater tendency toward higher burnout subscores. In addition, those DCs who owned their business; worked primarily in an acute, subacute, and/or chronic care environment; and depended on workers' compensation/personal injury as a primary source of payment for services render also had predisposition toward higher burnout subscores. Adding to these challenges, there were other chiropractic-specific variables that appeared to have a negative effect on burnout subscores including the following: having a musculoskeletal-focused practice (as opposed to subluxation based), having a work-related injury (perhaps from the physical demands performing manual therapy), witnessing the opposing philosophical perspectives within the chiropractic profession, and dealing with the inconsistent public opinion of the chiropractic profession. Despite the present study's observed lower EE among DCs, the presence of high EE observed in other similar professions raises the relevance of EE as a concern for DCs because it may ultimately increase the incidence of burnout (as per Maslach Tripartite theory), 15 attrition, and unprofessionalism and have a negative impact on the patientpractitioner relationship. 34,35 Emotional exhaustion is considered to be the core element of burnout, 21 and according to Maslach and Jackson, 36 the EE subscale primarily reflects the organizational and the social climate of the work environment. Interestingly, the DCs in this study showed moderate levels of EE when questioned about organizational (practice setting/type, reimbursement/regulation, therapeutic focus, and physical demands of practice) and social stressors (perception, public opinion, and varying philosophical views) that appear to hamper the profession. Given the negative consequences of high EE levels on individual health and job performance, 16,37 the present study reveals that creating conditions to prevent or minimize EE among DCs is important not only for DCs but also for the clients they serve and the organizations in which they are employed. Overall, this sample of DCs reported lower EE and DP scores and higher PA scores than did their medical, 16,38-43 nursing, 44-48 physical therapy, 33,49-51 occupational therapy, 33,49,52,53 and dentistry 35,54,55 colleagues who have been evaluated using the MBI-HSS. As a result, this group of DCs fared more favorably than did the subset of other health professionals on all 3 dimensions of burnout. Therefore, the findings from this study may serve as a catalyst for further conversation (intraprofessional and interprofessional) on the prevention and/or management of burnout amid similar professions. In the literature, age is the demographic variable that is most consistently correlated with burnout, with higher levels seen among workers younger than 30 to 40
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Table 6. Means and SDs for EE, PA, and DP Scores by Nominal Sociodemographic Factors EE Sociodemographic Sex Female Male Marital status Married Widowed Divorced Separated Never married Professional status Associate Independent contractor Sole practitioner Group practice Not direct care provider Own practice/business Yes No Associate DC present Yes No Primary practice setting Acute Subacute Chronic Wellness Not direct care Primary reimbursement Workman compensation/personal injury Cash-fee services Major medical Other Chiropractic focus Subluxation-based Musculoskeletal College focus Subluxation-based Musculoskeletal Location United States Canada International Have burnout Yes No Dealing with insurance increases burnout Yes No Work-related injury increases burnout Yes No Varying philosophical views increases burnout Yes No Public perception increases burnout Yes No
PA
Mean
SD
Mean
15.42 16.33
11.32 12.50
42.65 41.45
16.08 12.67 16.31 20.62 16.55
12.25 11.78 12.09 16.27 12.55
18.93 15.08 16.25 15.90 14.00
DP SD
Mean
SD
6.12 6.94
3.44 4.77
4.15 5.24
41.51 42.78 43.31 44.46 40.77
6.94 6.53 5.68 4.75 6.74
4.56 4.11 4.09 5.92 4.59
5.18 5.84 4.52 6.30 4.58
13.12 11.86 12.38 12.21 10.52
40.18 39.60 41.82 42.41 39.52
7.73 10.13 6.58 5.73 8.75
6.88 4.00 4.37 4.39 5.61
5.64 3.83 4.97 5.32 5.67
16.04 18.18
12.28 12.99
41.84 41.00
6.65 7.27
4.32 5.93
4.97 5.60
15.58 16.44
12.60 12.32
41.75 41.75
7.15 6.62
4.43 4.51
5.37 4.99
17.94 17.62 16.69 11.67 12.89
12.84 12.66 11.95 10.45 10.03
41.31 41.49 40.81 43.52 40.30
7.20 6.92 7.12 5.19 7.35
4.81 4.77 5.02 3.25 5.11
5.12 5.34 5.47 4.13 5.04
20.32 12.59 17.41 13.38
13.02 11.18 12.41 10.37
38.52 42.59 41.93 40.56
7.46 6.31 6.77 6.74
6.57 3.29 4.71 5.11
5.86 4.36 5.12 5.12
10.94 17.33
10.37 12.48
43.22 41.36
5.67 6.81
3.18 4.90
4.38 5.22
15.20 16.55
12.80 12.18
42.00 41.58
6.95 6.53
4.59 4.59
5.42 4.99
16.19 13.87 20.64
12.27 10.95 17.43
41.67 41.47 41.21
6.79 8.44 6.02
4.51 3.30 9.86
5.06 2.97 7.95
29.10 10.79
11.49 7.84
38.07 43.23
7.90 5.56
8.19 3.00
6.44 3.39
17.06 10.07
12.41 10.45
41.78 41.60
6.42 7.60
4.77 3.17
5.13 4.79
23.26 14.97
13.88 11.62
39.78 42.05
7.89 6.49
7.00 4.10
6.37 4.71
21.02 14.29
12.86 11.58
39.99 42.39
7.61 6.26
6.58 3.72
6.18 4.33
21.36 12.21
12.69 10.43
40.22 42.86
7.28 6.09
6.31 3.15
5.87 3.88
DC, doctor of chiropractic; DP, depersonalization; EE, emotional exhaustion; PA, reduced personal accomplishment.
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years. 32,37 In the present study, with 76% of respondents being older than 40 years, it is plausible that the underrepresentation of younger DCs may have resulted in lower levels of reported burnout on EE and DP and/or inability to see the true effect of age on burnout. However, the moderate association noted between age and subscale scores is consistent with several studies of physical and occupational therapists. 16,49,51,52,56 Maslach and Jackson 57 hypothesized that age reflects more than just the length of time on the job. With increased age, people tend to demonstrate more stability and maturity, have a more balanced perspective on life, and are less prone to excesses of burnout. In the current study, it was shown that EE and DP were significantly negatively correlated with age, such that as age increased, EE and DP tended to decrease. It was encouraging to see that longer durations in practice (experience) were associated with lower levels of EE—a finding similar to those reported by previous authors. 56,58 In the current study, as DC practice experience increased, EE tended to decrease. These finding are further supported by previous studies that found higher levels of EE and DP, as measured by MBI-HSS, in more recent graduates than those who had a longer work history. 51,56,59 In fact, Maslach and Jackson 37 suggest that age is confounded with work experience, so burnout appears to be more of a risk earlier in one's career. The reasons for such an interpretation have not been studied but should be viewed with caution because of the problem of survival bias—that is, those who burn out early in their careers are likely to quit their jobs, leaving behind the survivors who consequently exhibit lower levels of burnout. 37 The demographic variable of sex has not been a strong predictor of burnout (despite some arguments that burnout is more of a female experience) 37; however, it does play a significant role in the perception and origin of stress. 58 In the current study, female DCs had higher PA scores and lower DP scores compared with men's PA and DP scores; however, these results may also reflect the confounding of sex with occupation (eg, DCs are more likely to be male). As would be expected, a large percentage (89%) of the DCs surveyed indicated that they owned their business/ practice. Those DCs who did own their business had significantly lower DP scores compared with those who did not. Being entrepreneurs, the typical working conditions and responsibilities of DCs are likely to differ from that of other helping professionals whose primary care duties are traditionally hospital or clinic based. Te Brake et al 60 argue that certain specific aspects of entrepreneur-like occupations are reflective in deviating responses to the MBI. However, the impact of these responsibilities did not seem to have a major influence on this group of DCs' overall DP scores, suggesting that despite the hardships that may be associated with operating a business, DCs seemed to avoid
Journal of Manipulative and Physiological Therapeutics March/April 2014
distancing themselves from those receiving care, their clients. It was expected that the primary reimbursement type, practice setting, and therapeutic focus would affect burnout levels. Doctors of chiropractic who primarily worked in wellness-focused facilities, were subluxation based, and relied on cash-for-services rendered had significantly lower EE and DP scores and higher PA scores compared with those practitioners who worked in acute, subacute, and/or chronic setting, with a musculoskeletal focus, and who relied on either workers compensation/personal injury or major medical as the primary source of reimbursement for services rendered. This relationship is perhaps the combined end product of caring for a healthier population of clients (as opposed to ill) and the elimination of stressors that tend to coexist with the administrative challenges of billing and collections. Upon further reflection, another possible reason for this symbiotic relationship could be a result of the intrinsic uncertainties about reimbursement, which is ultimately influenced by changes in the external environment such as changes in the economy, managed care regulations, and the social climate. However, it should be duly noted and cited as a limitation that providing only 2 options (subluxation based/straight vs musculoskeletal/mixer) for focus of chiropractic work question may be argued as being limited. As such, present-day chiropractic has evolved to tolerate several other contentious and polar aspects of practice such as patient-centered vs self (doctor)-centered practice, evidence-based vs belief-based practice, holistic-wellness vs symptom-relief practice, marketing-based practice management vs referral-based practice, and separate and distinct profession vs integrative, health care team profession, among many others. An a priori assertion was proposed, which predicted a correlation between burnout subscales and the effect of legal scope of practice (restrictive or expansive) and the graduating college's academic focus (beyond accreditation mandates). Using the literature compiled from the American Chiropractic Association Web sites, the Chiropractic Resources Organization (http://www.chiro.org/ main/), the 19 chiropractic colleges located in the United States were categorized as either a straight/objective or mixer/reform by the principal investigator based on a sample of contemporary chiropractic materials. 5,10,18,19 For the first assumption, the 1-way ANOVA showed no statistical difference, thereby confirming that levels of burnout do not differ per geographical state. However, because there was one grouping variable that included all the states (separated), it was unlikely that any statistical differences would be found to begin with. For the second assumption, statistically significant but weak differences emerged, but there did not appear to be much of a difference of overall burnout values.
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Self-perception and/or identifying with the operational definition of burnout was notably the strongest association witnessed in this study. There was a large statistical difference between those DCs who acknowledged they had burnout and those who noted they did not have burnout. Here, respondents were first provided with Maslach's definition of burnout 15,37 and then asked to identify if they could identify with having symptoms of burnout presently. Those DCs who had symptoms of burnout (as per Maslach's definition) had significantly higher EE and DP scores and significantly lower PA scores compared with those who did not have symptoms of burnout. Among many possible explanations (extraneous and confounding), this relationship may support the notion of construct validity and the application of MBI-HSS 61 to the chiropractic profession. Perhaps the most compelling aspects of the results were in the unique DC stressors category. Doctors of chiropractic reported negative tendencies toward the varying philosophical perspectives within the profession and the negative public opinion of the chiropractic profession. These findings support the theoretical rational proposed, which merges job demands-resources model 62 and Maslach Tripartite theory 15 and thus warrants further investigation into their effects on job stress, attrition, and burnout within the chiropractic profession.
Limitations and Future Studies Several limitations must be kept in mind concerning the implications based on the results of this study. First, that this study was exploratory in nature and used a convenience sample of DCs must be recognized. In addition, the crosssectional nature of this study means that causal relation cannot be established. The sampling methodology involved a random selection of DCs from an e-mail directory; therefore, those DCs who were not included in the database and/or those who may have left the profession as a result of burnout would not have been invited to participate in the study. In fact, approximately 6% of the surveys returned indicated that the respondents were not currently in practice.
CONCLUSION The findings from this study indicate that the prevalence of burnout among the group of DCs who responded to the survey is remarkably low, and this group of DCs presented with lower levels of burnout compared with other health care professionals. The results from this present study begin to fill the void that exists within the chiropractic literature in relation to understanding the prevalence of burnout and its potential impact on the profession.
Williams and Zipp Burnout
Practical Applications • Overall burnout scores for DCs were significantly lower than health care norms. • Of the independent variables examined, statistically significant relationships were found between burnout subscales and the effects of sex, time dedicated to clinical care and administrative duties, source of reimbursement, the type of practice setting, the nature of practitioners' therapeutic focus, the location of chiropractic college, self-perception of burnout, the of effect of suffering from a work-related injury, the varying chiropractic philosophical perspectives, and the public's opinion of chiropractic. • Although DC in the United States had lower levels of burnout compared with other health care professionals, higher levels of EE remain workplace issues for this professional group.
FUNDING SOURCES
AND
POTENTIAL CONFLICTS
OF INTEREST
No funding sources or conflicts of interest were reported for this study.
CONTRIBUTORSHIP Concept development (provided idea for the research): SW, GZ. Design (planned the methods to generate the results): SW. Supervision (provided oversight, responsible for organization and implementation, writing of the manuscript): SW, GZ. Data collection/processing (responsible for experiments, patient management, organization, or reporting data): SW. Analysis/interpretation (responsible for statistical analysis, evaluation, and presentation of the results): SW Literature search (performed the literature search): SW Writing (responsible for writing a substantive part of the manuscript): SW. Critical review (revised manuscript for intellectual content, this does not relate to spelling and grammar checking): SW.
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