Predicting burnout among dental professionals in ...

[Downloaded free from http://www.jiaphd.org on Wednesday, September 28, 2016, IP: 82.157.50.38]

ORIGINAL ARTICLE Working conditions and personal characteristics: Predicting burnout among dental professionals in Mysore, India: A questionnaire survey Swati Harilal Chainani, Siddana Sunitha1, CVK Reddy1, Maurya Manjunath1, Sushma Rudraswamy1 Department of Public Health Dentistry, Yashwantrao Chavan Dental College, Ahmednagar, Maharashtra, 1Department of Public Health Dentistry, JSS Dental College and Hospital, Mysore, Karnataka, India Address for correspondence: Dr. Swati Harilal Chainani, Pitra Chhaya, c‑654/1307, Section 25, Sai Vasanshah Bunglow Area, Ulhasnagar ‑ 421 004, Mumbai, Maharashtra, India. E‑mail: [email protected]

ABSTRACT: Introduction: Dentistry is a profession demanding physical and mental efforts. Increased workload, stress, poorer mental health, and reduced job satisfaction, these factors might combine, to increase the level of “burnout” among dental practitioners. Aim: To assess

the burnout level among the dentist practising in Mysore city and to investigate the association between personal characteristics, working conditions and burnout. Materials and Methods: The study was conducted in the month of August‑September 2011. A predesigned and pretested questionnaire of 22 items called Maslach Burnout Inventory ‑ Human service Survey was distributed among the dentists to assess the burnout levels. The response was obtained using a Likert scale ranging from 0 to 6. Statistical analysis was carried out using Microsoft Excel and SPSS version 17 (SPSS Inc., Chicago, IL, USA). The data were subjected to mean, standard deviation, and contingency coefficient test at 5% level of significance. Results: Emotional exhaustion was found to be high in 31 (22.1%), moderate in 16 (11.4%), and low in 93 (66.4%) of the dentists. High level of personal accomplishment was found in 63 (45.0%), moderate in 45 (32.1%), and low in 32 (22.9%) dentists. Depersonalization was found to be low in 63 (45.0%), moderate in 45 (32.1%), and high in 32 (22.9%) participants. Conclusion: Of the 140 participants, 16 (11.4%) were found to be at a high risk. 118 (84.3%) in moderate risk and 6 (4.3%) in low risk of burnout.

Key words:

Burnout depersonalization, emotional exhaustion, Maslach burnout inventory, personal accomplishment

INTRODUCTION Dentistry is a stressful profession. Clinicians experience numerous workplaces, financial, practice management and societal issues for which they often are unprepared after finishing a university.[1] Dentists indicated that emotional strain of dealing extensively with other human beings, particularly when they are troubled or having problems, running behind schedule, causing pain, heavy work load, late and anxious patients as well as lack of positive feedback Access this article online Quick Response Code:

Website: www.iaphd.org

DOI: 10.4103/2319-5932.165282

313

are the most intense stressors in their work.[2] Working in such environment can lead to a psychological condition called Burnout. It is negative response to chronic job‑related emotional stress. It is a syndrome encompassing three coexisting domains:[3] Emotional exhaustion (EE) ‑ the person is exhausted emotionally or mentally. Depersonalization (DP) ‑ the person develops a negative, indifferent or cynical attitude toward the patients, clients, or co‑workers. Personal accomplishment (PA) ‑ tendency for people to feel This is an open access article distributed under the terms of the Creative Commons Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non‑commercially, as long as the author is credited and the new creations are licensed under the identical terms. For reprints contact: [email protected] How to cite this article: Chainani SH, Sunitha S, Reddy C, Manjunath M, Rudraswamy S. Working conditions and personal characteristics: Predicting burnout among dental professionals in Mysore, India: A questionnaire survey. J Indian Assoc Public Health Dent 2015;13:313-7.

© 2015 Journal of Indian Association of Public Health Dentistry | Published by Wolters Kluwer - Medknow

[Downloaded free from http://www.jiaphd.org on Wednesday, September 28, 2016, IP: 82.157.50.38] Chainani, et al.: Burnout among dentist, India

dissatisfied with their accomplishments and to evaluate themselves negatively.[4,5]

uniformity and to avoid misinterpretation by the study subjects.

Burnout results from people giving too much of their time, energy, and effort on the job over a long period of time without adequate time to recover physically or emotionally.[1] The values of burnout and its constituents among dental workers are amazingly high.[4,6‑9] Previous studies have indicated that burnout can lead to illness, absenteeism, early retirement, negative attitude, indifference to treatment outcomes, and to patient’s condition or needs.[2,4,7]

The inclusion criterion was those willing to participate in the study. Registered dentists who have migrated from Mysore and those who did not consent were excluded from the study. Final data were collected during the months of August and September 2011 by visiting the dental offices of the practitioners.

The affected dentist also tends to avoid any contact with people, whether they are colleagues, patients, friends, or even family.[1] Depression may be a consequence of the prolonged experience of burnout.[9] It can thus be considered as a serious risk to the dental profession, causing both a threat to the available workforce and personal tragedy for the individual.[10] In India, there is a dearth of information on burnout, and only few studies have been conducted. One focused on stress and burnout among the postgraduate students in a university where 21% of the total subjects were cases of burnout.[11] The other study focused on burnout experience among dental faculty and dental students where it found that third, final year and postgraduate students experienced more burnout than the others.[12] However, no study is conducted among the general dental practitioners who are in the profession for many years; hence, we conducted the current study to assess the burnout among the dentists of Mysore city, India.

Aims and objectives

• To assess the burnout level among the dentist practising in Mysore city • To investigate the association between personal characteristics, working conditions and burnout.

MATERIALS AND METHODS A cross‑sectional, questionnaire study was conducted among the dental practitioners of Mysore city. Approval from the Institutional Ethics Committee was obtained before initiating the study. A list of the practitioners in Mysore was made using data from the Dental Colleges of Mysore, Indian Dental Association ‑ Mysore branch, Telephone Directory and Just Dial Mysore services. After canceling the repeated entries in various sources, a final list was compiled and it consists of 180 dental professionals. A pilot study was conducted in the month of July 2011. The questionnaire was pretested among 18 dental professionals and revised accordingly to ensure

Journal of Indian Association of Public Health Dentistry Vol. 13, Issue 3, | July-September 2015

A self‑administered questionnaire consisting of two parts was distributed among the dentist. First part comprised the demographics and job‑related questions such as years of practice, kind of work, days of practice per week, working hours/day, number of patients/day, medications, frequency of vacation any other source of income as the possible indicators of workload were recorded. The second part was the measuring instrument‑Maslach Burnout Inventory (MBI). It is a list of 22 statements relating to feelings produced by contact between the care provider and care recipient (in this study, dentist and patient, respectively). Each of these statements relates to one of the three independent aspects (subscales) of burnout syndrome identified by Maslach. The three subscales are: EE, DP and (PAs). Response was obtained using a 7‑point Likert scale ranging 0 (never) – 6 (always) depending on how frequently they experience the feeling described in the statement. The Cronbach’s alpha coefficients for this study were: 0.67 for EE, 0.42 for DP, and 0.60 for PA.

Statistical analysis

Data were entered and analyzed using Microsoft Excel and SPSS version 17 (SPSS Inc., Chicago, IL, USA). The data were subjected to mean, standard deviation, and contingency coefficient test. The statistical significance level was set at 0.05.

RESULTS The response rate for this study was 77.7%. The study population comprised 78 (55.71%) males and 62 (44.28%) females with the mean age of 36.53 years. Among the respondents, 85 (60.71%) were graduates, whereas 55 (39.2%) were postgraduates in various specialties. EE was found to be high in 31 (22.1%) dentist, moderate in 16 (11.4%) and low in 93 (66.4%) [Table 1]. It was significantly associated with days of practice/week (93.5%, 6 days), working hours (61.3%, >10 h), number of patients seen per day (35.5%, >15 patients/day), medication intake and kind of work. The majority of the respondents with high levels of EE were consultants (P = 0.001). DP was found to be low in 63 (45.0%), moderate in 45 (32.1%) and high in 32 (22.9%) participants. It was significantly associated with working hours,

314


Table 1: Percentage distribution of subscales among dentist in Mysore

90

Subscale

Category

Cut‑off score

Percentage

70

EE (score 0-54)

High Moderate Low High Moderate Low High Moderate Low

≥27 19-26 0-18 ≥10 6-9 0-5 0-33 34-39 ≥40

45 2.1 22.9 22.9 32.1 45 22.1 11.4 66.4

60

DP (score 0-30)

PA (score 0-48)

EE – Emotional exhaustion, DP – Depersonalization, PA – Personal accomplishment

being higher among those practicing between 5 and 10 h/day (73.3%) (P = 0.012). High level of PA was found in 63 (45.0%) dentist, moderate in 45 (32.1%) and low in 32 (22.9%) dentist [Table 1]. PA was found to be higher among the majority of the practitioners with MDS qualification and those with other sources of income. Academicians (54.1%) and clinicians (49.2%) showed higher scores of PA. Of the 140 participants, 16 (11.4%) were found to be at a high risk. 118 (84.3%) in moderate risk and 6 (4.3%) in a low risk of burnout [Figure 1].

DISCUSSION The recognition of burnout as a public health problem led to its inclusion in the list of occupational diseases related to work.[1] Dentists, who are in contact with the patients, have to settle financial matters, maintain specific working posture, and work within the limited space of the oral cavity. These are some of the dental professional specificities which can lead to high levels of stress among them.[9] The literature has shown that the severity of this stress, collective with factors such as lack of energy and enthusiasm, feelings of exhaustion, and emotional instability, may lead to the onset of burnout syndrome.[13] To address this situation, there is a need for an early identification of symptoms related to burnout, which should preferably take place when workers are still in training, that is, during their graduate course. Maslach states that the unique thing about burnout is that stress arises from social interaction between the dentist and the patients and “although personality does play some part in burnout, the bulk of the evidence is consistent with the view that burnout is best understood (and modified) in terms of situational sources of job‑related, interpersonal stress.”[4] Although the term conveys, at least in part, a description of a psychological syndrome; the phenomenon has become a legitimate area of study.[14]

315

84.3%

80

50 40 30 20 10

11.4%

4.3%

0 low

medium

high

Figure 1: Overall burnout among dentist in Mysore

Overall, it is apparent from this study that the dental professionals of Mysore are at a moderate risk of burnout on all three subscales of the MBI. These findings corroborate parallel studies of stress among general dental practitioners.[5] Wherein practice‑related aspects such as time pressures, patient related problems and management of auxiliary staff and most important the lack of career perspective were regarded as the crucial aspects of burnout. Burnout is assessed in terms of the three subscales score: EE, PA, DP. In this study, it was found the EE was positively associated with years of practice, days of practice/week, working hours, number of patients seen per day. Similar results were obtained in the study conducted by Osborne and Croucher among the British dental practitioners.[4] This could be possibly due to increased emotional load due to greater volume of patients treated with little time to recover physically and emotionally. EE in this study was found to be more in consultants as compared to clinicians and academicians which could be due to stress in time management, staying on schedule at various clinics and difficulties in coping with uncooperative patients.[15] EE was also greater among the dentists who were on some kind of medication which is in accordance with the study conducted by Rada and Johnson‑Leong.[2] The possible explanation being reduction in stress tolerance, that also experienced their workload as being more unsatisfactory, were more burdened by anxiety, had poorer psychosomatic health and less confidence in the future than dentists without symptoms.[1] In our study, dentists with postgraduate qualifications exhibited higher levels of PA, which is similar to Osborne’s sample.[4] This may be due to various reasons like achieving the degree may itself be important, benefits of those qualifications when applied to general practice routine and more diverse professional opportunities to which these qualifications might allow access. Increased



sense of PA among those with other sources of income might be due to increased sense of financial stability.[16]

the association between burnout symptoms and work environment.

PA was found to be more among the clinicians as also seen in the study conducted by Osborne and Croucher.[4] This may be attributed to high levels of control, autonomy, match between technical aspirations and a practical outcome. However, some studies show that those working in exclusive practice may be more emotionally drained with reduced future perspective as they are professionally isolated and often have to rely on his own emotional resources in the clinical situation.[17]

Future studies require the further addition of more items to the respective scales and performing item and factorial analyses. Moreover, the use of additional instruments, such as organizational commitment questionnaire, job satisfaction survey, workload scale, or interpersonal conflict at work scale to supplement the MBI will enrich future analyses and provide more alternative explanations for what is and is not found.

Dentists who take on a teaching role in addition to their clinical role may increase their levels of stress, but there is also evidence that this dual role may reduce job‑related stress.[1] The increased levels of PA among them may be due to lessened isolation, increased self‑esteem in response to attention of students, a sense of autonomy over what and when to teach, power over those in junior position, added interest in patients as a source of teaching, sense of helping students and patients.[17] PA associated with smoking and alcohol, as also reported by Newbury‑Birch et al.[18] A decreased sense of PA may be experienced by the dentist owing to stressors in early years of practice such as number of patients seen per day, not knowing what to expect as an associate, fear of making mistake, belief that patients can be too demanding. All this might compel the professionals to use smoking and alcohol as a stress relieving measure. DP implies feeling detached and hence distancing of patient when interacting during an examination or treatment session. In the present study, it was significantly associated with number of working hours and the thoughts about quitting dentistry as profession and opting for other profession. This was also reported by Humphris[14] and Osborne and Croucher.[4] The reason stated being the dentist spends more proportion of the week into practice so as to meet the self‑imposed financial targets and thereby feeling forced to work more, and this in turn reduces the time available for each individual.[14] This increased workload along with reduced sense of PA may tempt the dentist to quit dentistry and opt for another profession leading to loss of valuable dental manpower to other discipline. However, more research needs to be conducted on this aspect of burnout.

Limitations The assessment of overtime hours and its association to burnout was not performed. This might only explain some of the varying levels of burnout. The data were cross‑sectional and collected from self‑reports which do not allow for causal conclusions. Individuals with high negative affectivity may perceive their work context more negatively, which would artificially strengthen


Suggestions for coping stress

• Incorporation of Stress management, financial and business management skills in the dental curriculum • Stress management workshop focusing on stress relaxation techniques such as deep breathing, progressive effective relaxation of areas of the body, listening to audiotapes of oral instructions on relaxation techniques and meditation • Training in time management, communication and interpersonal skills in how to deal with conflict and confrontation • Workshops to develop Interviewing skills and effective listening skills • Training in management of difficult, uncooperative, anxious, and aggressive patients • Use of social support systems such as study groups or organized dental meetings • Professional help or counseling services if stress affects person’s normal lifestyle.

CONCLUSION Burnout appeared to be common among the dentists of Mysore city. Burnout among the dentists detracts from quality and quantity of services and care rendered which may subsequently contribute to poor patient outcomes and health infrastructures.

Financial support and sponsorship Nil.

Conflicts of interest

There are no conflicts of interest.

REFERENCES 1.

Puriene A, Janulyte V, Musteikyte M, Bendinskaite R. General health of dentists. Literature review. Stomatologija 2007;9:10‑20. 2. Rada RE, Johnson‑Leong C. Stress, burnout, anxiety and depression among dentists. J Am Dent Assoc 2004;135:788‑94. 3. Thorsen VC, Tharp AL, Meguid T. High rates of burnout among maternal health staff at a referral hospital in Malawi: A cross‑sectional study. BMC Nurs 2011;10:9. 4. Osborne D, Croucher R. Levels of burnout in general dental practitioners in the south‑east of England. Br Dent J 1994;177:372‑7.

316

[Downloaded free from http://www.jiaphd.org on Wednesday, September 28, 2016, IP: 82.157.50.38] Chainani, et al.: Burnout among dentist, India 5. Maslach C, Leiter MP. Early predictors of job burnout and engagement. J Appl Psychol 2008;93:498‑512. 6. Baran RB. Myers Briggs Type Indicator, burnout, and satisfaction in Illinois dentists. Gen Dent 2005;53:228‑34. 7. te Brake H, Bloemendal E, Hoogstraten J. Gender differences in burnout among Dutch dentists. Community Dent Oral Epidemiol 2003;31:321‑7. 8. Gilmour J, Stewardson DA, Shugars DA, Burke FJ. An assessment of career satisfaction among a group of general dental practitioners in Staffordshire. Br Dent J 2005;198:701‑4. 9. Gorter RC, Freeman R. Burnout and engagement in relation with job demands and resources among dental staff in Northern Ireland. Community Dent Oral Epidemiol 2011;39:87‑95. 10. Alemany Martínez A, Berini Aytés L, Gay Escoda C. The burnout syndrome and associated personality disturbances. The study in three graduate programs in Dentistry at the University of Barcelona. Med Oral Patol Oral Cir Bucal 2008;13:E444‑50. 11. Shetty A, Shetty A, Hegde M, Narasimhan D, Shetty S. Stress and burnout assessment among post graduate dental students. Nitte Univ J Health Sci 2015;5:31‑6.

317

12. Reddy S, Reddy RL, Ramesh T, Vijaylaxmi N, Swapna LA, Singh RT. Burnout among dental students and dental faculty in a dental college. Indian J Public Health Res Dev 2014;5:64‑8. 13. R a j p u r o h i t L L , A n k o l a A V , H e b b a l M , M e h t a N . A questionnaire study to evaluate the burnout syndrome and stress among dental students from two universities. J Dent Res Sci Dev 2015;2:8‑12. 14. Humphris G. A review of burnout in dentists. Dent Update 1998;25:392‑6. 15. Wilson RF, Coward PY, Capewell J, Laidler TL, Rigby AC, Shaw TJ. Perceived sources of occupational stress in general dental practitioners. Br Dent J 1998;184:499‑502. 16. Maslach C, Jackson SE. The measurement of experienced burnout. J Occup Behav 1981;2:99‑113. 17. Rutter H, Herzberg J, Paice E. Stress in doctors and dentists who teach. Med Educ 2002;36:543‑9. 18. Newbury‑Birch D, Lowry RJ, Kamali F. The changing patterns of drinking, illicit drug use, stress, anxiety and depression in dental students in a UK dental school: A longitudinal study. Br Dent J 2002;192:646‑9.
