Prevalence and risk factors of Burnout syndrome in emergency physicians of public hospitals in the Principality of Asturias, Spain

Introduction Burnout syndrome (BS) is a state of fatigue or frustration produced by dedication to a cause, lifestyle or relationship that does not produce the expected reinforcement. BS has three dimensions: Emotional Exhaustion (EE), Depersonalization (D) and Low Personal Achievement (PA) and can be measured with the Maslach Burnout Inventory (MBI). The objective was to determine the prevalence of BS among hospital emergency physicians in the Principality of Asturias and its relationship with sociodemographic, occupational, health, and perceived stress variables, as well as knowing the risk of suffering BS. Methods Multicenter observational cross-sectional study among general practitioners of the emergency services of reference hospitals in the eight health areas of the Principality of Asturias. A questionnaire with 48 questions in two sections was used: (1) Sociodemographic, labor, job satisfaction, perceived health, and stress data; and (2) MBI Questionnaire. Results There were 137 valid questionnaires (response rate 70.26%). 18.2% of the physicians had BS. In the EE dimension, 47.45% had a low level of burnout, 26.28% a medium level and 26.28% a high level. In dimension D, 16.79% presented low levels of burnout, 30.6% medium level and 52.55% high level. In the PR dimension, 1.46% had high levels, that is, a low level of burnout, 21.9% had a medium level of burnout, and 76.64% had low levels of PA that is related to a high level of exhaustion In relation to the risk of suffering burnout, 70.1% had a high risk while 11.7% had no risk.


Introduction
The Syndrome of "burnout" (BS) is a kind of response to prolonged stress due to work factors affecting negatively mind a person in the form of physical and mental exhaustion. It was first described in 1974 by Freudenbergen as a state of fatigue or frustration that results from dedication to a cause, lifestyle, or relationship that does not produce the expected reinforcement. [1] . A few years later, Maslach studied BS in workers from different fields, especially health, and associated with absenteeism, or to low morale and even alcoholism, mental illness, family conflict and suicide [2] .
In 1981, Maslach and Jackson defined the three dimensions of the syndrome: (I) Emotional exhaustion (EE) as a situation of exhaustion of energy and emotional resources as a consequence of daily contact and continued with the people to be cared for and who present problems or are problematic; (II) Depersonalization as the development of negative attitudes and feelings towards the recipients of work and personal fulfillment, and (III) and Low Personal Achivement as the tendency of professionals to qualify negatively in relation to the work they do and deal with people) [3] . Maslach and Jackson also developed a measuring instrument to detect BS, the Maslach Burnout Inventoy (MBI), a self-administered questionnaire about personal feelings and ways of acting in the professional field towards people and their work. [4] .
Due to the specific characteristics of healthcare work (high pressure, demand for results, lack of adequate rest, excessive hours of work or civil and criminal liability for any medical act), the health personnel of the emergency and emergency services are a group with high risk of suffering from BS [5] , which can affect the quality of healthcare and increase self -medication and suicide rates among professionals [6] . One of the aspects that has shown to increase the prevalence of burnout is a high workload. [7] .
The objective of this work was to determine the prevalence of burnout among the emergency physicians of the reference hospitals of the eight health areas of the Principality of Asturias (Spain) and its relationship with the sociodemographic, occupational, health status and perceived stress variables, as well as study the risk of suffering BS. In addition, the three dimensions that characterize burnout syndrome and their relationship with these variables were analyzed. Method A multicenter observational cross-sectional study among general practitioners of the emergency services of reference hospitals in the eight health areas of the Principality of Asturias was made using a questionnaire with 48 items divided in two sections: (I) Sociodemographic, labor, job satisfaction, perceived health, and stress data; and (II) MBI Questionnaire.
The inclusion criteria were being a doctor assigned to the emergency services of reference hospitals in the health areas of the Principality of Asturias, being service personnel during the data collection phase and agreeing to participate. The questionnaires collected without filling out or incorrectly completed were excluded from the study.
We used a questionnaire with 48 questions divided into two sections: (I) Sociodemographic, labor data, job satisfaction, perceived health and stress; and (II) MBI. In section I the following sociodemographic variables were collected: age, sex, marital status and number of children.
Regarding labor variables: work hospital, professional exercise time (not counting the training period), exercise time in the emergency department, working condition, offering the center to carry out training activities, carrying out training activity in the last year and consideration of your work as a vocational emergency professional. Regarding the variables of job satisfaction: desire to change work shifts, satisfaction with the work performed, satisfaction with the support of the management of the center, satisfaction with the support of the management of the emergency department, satisfaction with colleagues work and satisfaction with the global assessment of professional experience. About the variables of perceived stress and health: definition of self health status, number of sick leave in the last year with the number of days, perception of stress in daily work ("Does the development of your daily work stress? ") and perception of the influence of stress in their own state of health (" What influence do you consider occupational stress to have on your state of health? "). In section 2, the MBI was collected, which is subdivided into 3 scales: Emotional Exhaustion (EE) subscale, which refers to the decrease or loss of emotional resources or to having feelings of being overwhelmed and emotionally tired due to the demands of work; Depersonalization subscale (D), referring to negative feelings and attitudes towards the patient and to the impersonality and not very sensitive attitude towards the people attended and the Personal Achievement (PA) subscale, related to feelings of competence, efficiency and accomplishment at work.
To assess the degree of burnout, the values obtained in each dimension were taken as a reference, using a scale of three categories: Low (EE≤15, D≤3, PA ≥40), Medium (EE:16-24, D:4 -9, PA: 34-39) and High (EE≥25, D≥10, PA<34) proposed by Gil Monte and Peiró [8] . The variable " suffering from BS" was considered as the presence of high scores of EE and D with low PA. And the rest of the combinations of the three dimensions were considered as not suffering from BS.
For the stratification of the BS risk, the recommendations of Frutos were followed, which includes seven strata [9]  The study was approved by the Research Ethics Committee of the Principality of Asturias and previous communications were maintained with each Department head to report on the study. Each participant was informed individually in the initial part of the survey, defining participation as voluntary and anonymous, guaranteeing maximum confidentiality in the data collection and analysis process. The completion of this questionnaire implied the acceptance of professionals to participate in the study. For confidentiality reasons, the names of the hospitals are omitted and they are referred to with a numerical code not corresponding to the health area number.
For data analysis, the statistical software package IBM SPSS Statistics, version 24.0 was used. The Shapiro Wilk test was applied to check the normal distribution of the three dimensions of the MBI questionnaire. None of the three dimensions followed a normal distribution: (p = 0.978 for EE; p = 0.953 for D; p = 0.971 for PA). For the comparison of means, Man n -Whitney tests were used, in the case of two samples, and the Kruskal-Wallis tests for more than two samples. In all cases, the existence of differences was assumed when the significance was less than 5% (p <0.05).

Results
The Principality of Asturias is one of the autonomous communities that make up the Spanish State, located in the north of the country and with a population of 1,028,244 inhabitants. Its health service has 8 health areas and each of them has a public reference hospital with emergency services in which a total of 195 doctors work. 137 (70.2%) of the 195 emergency department physicians agreed to participate in the study (response rate 70.26%.). Table 1 shows the description of the population according to the sociodemographic, labor, health and perceived stress variables and age groups. The mean age of the participants was 45.6 years (SD=9.17, range 29 to 68 years). 86 (62.8%) were women; 93 (67.9%) were married or in a stable relationship and Qeios, CC-BY 4.0 · Article, August 22, 2023 86 (62.8%) had children. 58 (42.3%) were doctors with a permanent position and 79 (57.7%) were interim or eventual. The average number of years of professional practice, excluding the specialized training period, was 15.93 (SD=9.79) and the average number of years worked in an Emergency Department was 11.62 (SD=9.88). 119 (86.9%) of the physicians considered work as an emergency physician as vocational and 86 (62.8%) did not want to change their working hours. 123 (89.9%) were satisfied with the work they do and 110 (80.3%) with their overall professional experience. A total of 103 physicians (75.2%) were satisfied with their co-workers and 91 (66.4%), with the management of the Emergency Department. However, 106 (77.4%) were not satisfied with the management of the hospital. 19 physicians (13.9%) defined their own health status state as negative; 100 (73%) considered that daily work causes them stress, and 80 (58.4%), that work stress has some kind of influence on their health status. 70 doctors (51.1%) did not receive any offer from their hospital to carry out training activities, and 113 doctors (82.5%) had carried out some training activity in the last year.  dimensions with high values, 70.1% of the physicians had a high risk of suffering burnout and 11.7% had no risk.    Mann-Whitney test performed on the above variables. Mann-Whitney test performed on the above variables.

Discussion
The main objective of this study was to analyze the prevalence of BS in doctors working in the Emergency Department of the eight Asturian hospitals in the public network. The results have shown statistically significant differences regarding the presence of BS in some of its three dimensions in doctors. Other authors have found a mayor prevalence of BS scales AE and PA [10] .
There are authors indicating no association between prevalence of BS and the type of hospital service in wich the doctor works (Neurology, Pneumology and Cardiology) [11] , However, other studies [12] [13] [14] found an statistically significant association between working in a particular service and suffer BS, but influenced by the professional category. These discrepancies can be due to various reasons such as the use of different inclusion criteria or sample size of the study, which means that the results are not comparable.
On the other hand, it is important to note that BS can lead to other psychiatric disorders. Motta de Vasconcelos showed the relationship between BS and depression is statistically significant, making necessary to implement measures that contribute to reducing the prevalence of this syndrome [15] . Several authors have proposed preventive measure as the development of communication skills, the improvement of working conditions [16] [17] , the development of self-efficacy training programs to improve personal resources, the opportunity to participat in the design of work programs, [18] and to adopt organizational strategies to reduce both the incidence and prevalence of BS [19] . One of these strategies would be to decrease the doctor-patient ratio reducing the workload of physicians. According to the results of these investigations, it seems necessary to pay special attention to emergency professionals with higher scores on the burnout scales to avoid the appearance of this type of pathology.
This study has some limitations to consider. One of the risk factors of BS is turnicity and 40% of participants did not answer the question regarding the hospital complex shifts system. Due to turnicity, it is probable that some doctors have not received the questionnaire to fill out.
According to the results obtained in this study, is necessary to focus actions aimed at preventing BS in aspects such as adequate work schedules, management, leadership and continuous training. Special attention has to be paid to emergency doctors with the highest score on the burnout scales, implementing work measures that contribute to reducing the prevalence of this syndrome.
Physicians who work in the emergency services of our public hospitals show a prevalence and a risk of suffering BS related to specific aspects of their professional practice that are identifiable (work hours, continuous training, leadership of the department heads, participation in decision making, etc.). Many of these risk factors are preventable through proper organizational strategies. For this reason, the health authorities and those in charge of hospitals should implement general measures aimed at reducing burnout among the doctors on their staff and, particularly, among those doctors in the emergency services who obtain a higher score on the burnout scales, in order to avoid the impact that this problem has on the safety and quality of healthcare in emergency services.