BURNOUT, SENSE OF COHERENCE, AND HEALTH STATUS IN NEW YORK CITY HIV SERVICE PROVIDERS

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BURNOUT, SENSE OF COHERENCE, AND HEALTH
STATUSIN NEW YORK CITY HIV SERVICE PROVIDERS

• José E. Nanín, EdD, CHES
• NYC DOH HIV Training Institute
• and
• Teachers College, Columbia University
•  

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BURNOUT

• a state of psychosocial and physical exhaustion
  that results from chronic exposure to high levels
  of stress with little personal control
  (Sarafino, 1998).
• term first introduced by Freudenberger in 1973
  based on observations of volunteers involved in
  the free clinic movement in the 1960s
• Maslach (1978) provided empirical evidence and a
  measurable construct

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MASLACHS DEFINITION OF BURNOUT

• a psychosocial condition of emotional exhaustion,
  depersonalization, and reduced personal
  accomplishment
• an individual stress experience embedded in a
  context of complex social relationships
  involving the persons conception of both self
  and others (Maslach and Goldberg, 1998, p. 64)

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DIMENSIONS OF BURNOUT

• Emotional Exhaustion feelings of being
  emotionally overextended and depleted of ones
  emotional resources
• Depersonalization the negative, callous, or
  excessive detached response to other people,
  including a sense of diminished idealism
• Reduced personal accomplishment diminished or
  absence of feelings of competence and
  productivity at work encompassing a lowered
  sense of self-efficacy

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RESILIENCE

• ability to bounce back from adversitya
  challenge every human eventually faces in
  living (Dyer and McGuinness, 1996, p. 276)
• More specifically, the capacity for successful
  adaptation, positive functioning, or competence
  despite high-risk status, chronic stress, or
  following prolonged or severe trauma (Egeland,
  Carlson, and Sroufe, 1993, p. 517)

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RESILIENCE AND SOC

• In this study, resilience is measured via sense
  of coherence (SOC), a construct of human
  resilience, in which ones world and everyday
  occurrences in that world are perceived as
  comprehensible, manageable, and meaningful.
  (Antonovsky, 1996)

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HEALTH

• Based on biopsychosocial model (Engel, 1977)
• a positive state of physical, mental, and social
  well-beingnot simply the absence of injury or
  diseasethat varies over time along a continuum
  (Sarafino, 1998, p. 4)
• health is seen as a dynamic entity along the
  illness/wellness continuum with death on one
  end and optimal health on the other, suggesting
  how health and sickness are not entirely
  separate concepts, just overlapping phenomena
  (Sarafino, 1998, p. 4)

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Why was this study conducted?

• Burnout has been documented by many researchers
  to be highly prevalent in the HIV field, as well
  as in the general health and human services
  field. (Bennett, Miller, and Ross, 1995 Maslach
  and Leiter, 1997 Wells, Kutscher, Seeland,
  Selder, Cherico, and Clark, 1989)
• Anecdotal evidence revealed that burnout was
  having a negative impact on job performance and
  service delivery to clients.

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• Many HIV service providers were complaining about
  being burnt out from their jobs in HIV. This had
  a negative impact not just on their jobs, but on
  their abilities to learn how to do their jobs
  better by attending trainings.

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Aims of the Study

• To determine the prevalence of burnout
• To determine levels of sense of coherence
• To assess health status
• To explore the relationships between selected
  demographic and work-related variables and the
  main variables of interest
• To determine the best predictors of the main
  variables of interest

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Sample and Method

• Design cross-sectional survey
• Convenience sample 150 HIV service providers who
  attended classes at the HIV Training Institute of
  the New York City Department of Health from
  November 2000 to February 2001
• Surveys with consent forms attached were
  distributed at the start of each class session.
• Informed consent form was read aloud by the P.I.
  and had to be signed by participants before any
  surveys were completed.
• NOTE Surveys were tracked by a pre-determined
  code number that was not associated with persons
  name on the consent form.

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Surveys

• Maslach Burnout Inventory (MBI)
• measures the three burnout dimensions of
  emotional exhaustion, depersonalization, and
  personal accomplishment
• Demographic/Background questionnaires
• age, sexual orientation, years married, religion,
  etc.
• Orientation To Life Questionnaire (OTLQ)
• measures resilience through Sense of Coherence
• RAND Medical Outcomes Survey SF-36 (RAND/MOS)
• measures health status

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Reliability of Measurements
SIGNIFICANT FINDINGS

• MBI (3 scales) coefficients alpha from .68 to
  .88
• OTLQ coefficient alpha of .50
• RAND/MOS (8 scales) -- coefficients alpha from
  .61 to .91

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Sample Profile (N 150)

• Female (72)
• Black and Latino (61)
• Catholic and Protestant (48)
• Not married (77)
• Heterosexual (79)
• Attended college and above (61)
• Associates and Bachelors degrees (54)
• Social services and counseling (45)
• Front-line staff (including trainers) (66)
• Have had up to 10 days of training (67)

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• Often / very often receive supervision (54)
• Up to 50 of clients are PLWHIV (60)
• Mean age 35.64
• Mean number of years in HIV field 3
• Mean level of religiosity 3.95 (on scale of 1
  to 7) -- Moderately religious
• Mean hours worked per week 35.86
• Mean number of years at present job 2.72
• Mean number of years in helping field 4.99

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Burnout Prevalence(Aim 1)

• MBI measured level of burnout via 3 subscales
  (i.e., Emotional Exhaustion, Depersonalization,
  and Personal Accomplishment). To streamline data
  analysis, a composite score was derived.
• The composite burnout score, which ranges from a
  low of 0 to a high of 97 in this sample, attained
  a mean of 46.82 (SD 18.75).
• Low burnout, which comprises the range of 0 to
  54, existed among 67 of the sample.
• YETamong the subscale scores, 78 fell into the
  low-to-moderate personal accomplishment
  categories.
• NOTE Low personal accomplishment is a
  characteristic of high burnout.

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Level of Resilience(Aim 2)

• Resilience was measured via the OTLQ, which
  quantifies the construct of Sense of Coherence.
• Sense of Coherence scores can range from a low of
  29 to a high of 203.
• The mean Sense of Coherence score was 144.8 (SD
  22.73).
• Moderate SOC ranges from 134 to 156. Thus,
  resilience via Sense of Coherence was moderate in
  this sample.

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Level of Health Status(Aim 3)

• Health status was measured via 8 subscales of the
  RAND/MOS Survey. To streamline data analysis, a
  composite score was derived.
• The composite health status score, which ranges
  from 0 to 790 in this sample, attained a mean of
  607.45 (SD 123.46).
• When broken down categorically, moderate health
  status comprises a range from 565 to 687. Thus,
  most members of this sample experience moderate
  health status.

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Relationships with Burnout(Aim 4)

• Burnout had a significant negative relationship
  with
• age (r -.21, p lt .05)
• level of religiosity (r -.22, p lt .05)
• SOC (r -.51, p lt .01)
• health status (r -.49, p lt .01)

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• Domestic partnership status was found to have a
  significant effect on burnout (F 3.01, p
  .05).
• Post hoc Scheffé contrast tests revealed that the
  means between the Yes and No groups were
  significantly different (a .05). Thus,
  respondents in a domestic partnership experienced
  less burnout than respondents who are not in a
  domestic partnership.

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Correlates of SOC(Aim 4)

• SOC was positively correlated with
• age (r .21, p lt .05)
• level of religiosity (r .31, p lt .01)
• health status (r .56, p lt .01)
• As mentioned before, SOC was negatively
  correlated with burnout (r .51, p lt .01) .

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• Sex was found to have a significant effect on SOC
  (t -2.13, p lt .05).
• SOC means for males and females were
  significantly different from each other. Thus,
  female respondents possessed significantly more
  SOC (i.e., more resilience) than males.
• Marital status was found to have a significant
  effect on SOC (F 4.29, p lt .05).
• Post hoc Scheffé contrast tests revealed that the
  means between the single and married groups were
  significantly different (a lt .05). Thus, married
  respondents in this sample were significantly
  higher in SOC (i.e., more resilient) than single
  respondents.

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Correlates of Health Status(Aim 4)

• Health status was positively correlated with
• level of religiosity (r .18, p lt .05)
• highest level of school completed (r .23, p lt
  .01)
• SOC (r .56, p lt .01), as mentioned
• Health status was negatively correlated with
  burnout (r -.49, p lt .01), as mentioned.

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Predictions of Variables of Interest(Aim 5)

• Predictors for burnout were determined. The best
  predictors of the composite burnout score were
  SOC, health status, and domestic partnership.
  These 3 variables explained 33 of the variance
  in burnout (ß -.49, p lt .01).
• Predictors of SOC included health status,
  burnout, level of religiosity, sex, and marital
  status. These 5 variables were able to explain
  40 of the variance in SOC (ß .50, p lt .01).
• Predictors of health status included 3
  variables SOC, burnout, and highest level of
  school completed. They explained 36 of the
  variance (ß .50, p lt .01).

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Limitations of Study

• Use of volunteers (i.e., only people who gave
  consent) Self-selection bias
• English surveys were administered.
• Those with limited English reading ability may
  have provided useful and important information

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• No deception was used.Effects from demand
  characteristics
• Respondents knew what the study was about
• May have skewed the results
• P.I. administered the surveys. Experimenter
  effect
• Expectations may have influenced responses
• Low reliability of OTLQ
• Only self-report measures were used.
• More direct measures may have provided more
  accurate information

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Implications

• Even though 67 reported experiencing low burnout
  (based on the composite score), among the
  subscales, there were 78 of respondents who
  reported low to-moderate personal
  accomplishment, which is characteristic of high
  burnout.
• Service providers may not be fulfilled with their
  jobs even though they are performing their jobs
  and/or staying in the HIV field.

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• Administrators need to develop interventions to
  help their employees feel more personal
  accomplishment in their work.
• In addition, employees themselves may need to
  access counseling/therapy and other self-help
  resources to help them reframe their work goals
  so that they may feel more fulfilled about the
  work they do or to pursue other goals that may be
  more fulfilling.

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• Research implications
• Replication in other U.S. AIDS epicenters
• San Francisco, Los Angeles, among others
• Larger sample size
• Better representation of HIV service providers
• More meaningful results
• Conduct similar studies in areas of the world
  like South Africa where there is rising incidence
  of HIV

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• Noteworthy remarks
• AIDS is presently considered a manageable disease
  in the US yet, in developing areas of the world,
  like sub-Saharan Africa and South and Southeast
  Asia, the epidemic has multiplied three-fold and
  six-fold, respectively (Schoub, 1999).
• Burnout, resilience, and health status in HIV
  service providers of countries in these areas,
  especially South Africa, are worth investigating
  to foster new ideas that can make HIV/AIDS a
  manageable disease in those countries, as it has
  become here in America.

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Useful References

• Maslach, C. and Leiter, M. P. (1997). The truth
  about burnout. San Francisco, CA Jossey-Bass.
• Skovholt, T. M. (2001). The resilient
  professional. Needham Heights, MA Allyn Bacon.

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