At present there is unanimity in the specialized literature about which professional groups are most likely to develop the Burn-out Syndrome within healthcare institutions. At the same time, there is no standardized way of evaluating vulnerability to such professional burn-out. The available standardized methods, such as Christina Maslach’s MBI, can only account for irreversible functional changes in the individual after they have already taken place [13
]. In light of this fact, the high distress levels and common occurrence of professional burn-out within medical institutions that are funded by the national budget of Bulgaria have prompted our interest in this subject.
Given the above assumptions, our objective is to design an intervention with a new working method that can give a complex assessment of the psychological climate of healthcare organizations. It will aim at early assessment of the process, thereby helping to reduce and prevent burn-out.
According to our model, there are vulnerable groups of people for whom there is an effective way of preventing professional burn-out by psychosocial intervention. The Burn-out Syndrome is a type of professional exhaustion, which takes place in three consecutive stages [14
] that differ in their manifestations and intensity. Therefore, monitoring of the interaction between the psychological functioning of the individuals with the organizational climate in terms of psychological and social wellbeing should occur between the first two stages of the process – flame-out (i.e. stress of futile effort) and burn-out (i.e. exhaustion and demoralization). This early period in the burning process is propitious to identify means of intervention for the sake of preservation and recovery of the psychological potential of the workers in such vulnerable groups of medical specialists. At an earlier stage, the phenomenology of professional ‘burning’ is not difficult to differentiate from the symptoms of psychoemotional stress, whereas at a later stage (described by the term “rust out”), there may be less benefit from psychological interventions as the harm is thought to be irreversible. We are choosing to focus on early intervention, but hope that late interventions might also be helpful in future work.
According to our hypothesis, the high-risk pattern that accounts for vulnerability to professional burning within particular sectors of the healthcare system has three components. It includes characteristics of the interaction between the psychological and organizational climate that is combined with the personal traits of the workers. As a result, Burn-out Syndrome has three dimensions that can be measured and which are shown in Box 1.
As is evident, our model is focused on two crucial determinants of exhaustion of professionals within the healthcare system: stressors in the psychological climate of the organization and vulnerabilities in the personal mental health of the workers. The dimensional description of the psychological climate is carried out according to the methods of Koys and De Cottis, courtesy of the authors and according to their working definition:
“The psychological climate is an empirically based, diverse, long-lasting and perceptive phenomenon that is freely shared among the members of a particular organizational department. Its main function is to regulate and direct the personal demeanor towards that type of conduct, which corresponds to the needs of the organization” [17
In their research, the authors find more than 80 measurable characteristics of the psychological climate. They say that it is vital that we distinguish between the psychological climate of the organization and the work satisfaction of people within the organization.
Koys and De Cottis have studied some criteria that describe the psychological climate. However, these criteria evaluate the conduct of individuals, which is not part of the aspect of the organizational structure. Therefore, the authors pay no more attention to the criteria that serve as an index when forming the specific characteristics of the organizational structure. The analysis of the facts and the validation that is carried out are used as means of control and contribute to the removal of all criteria that apply to more than one sector of the organization. As a result, only 45 of the original 80 criteria were retained for describing the climate. These criteria are distributed in 8 basic categories, set out in Box 2.
Responses are rated according to a 7-class Likert scale. It is noteworthy that these measures of psychological climate can distinguish a climate of unity and connectedness among the workers, which accepts the fallibility of individuals while encouraging mutual support and interdependence and a climate of separateness which harshly demands that people strive to be error-free. The difference between a climate of unity versus a climate of separateness can be crucial as an external influence that triggers burn-out in vulnerable individuals.
The second determinant is measured by the personality profiles of individuals within the organization. Here, personality is observed along with how well a person is able to function in the teams and groups that make up the organization. Personality is studied through descriptive and causal analyses of the biological, social and psychological determinants of human behavior. One component of personality is temperament, which includes vulnerability to anxiety (i.e. high Harm Avoidance), anger and resentment (i.e. high Novelty Seeking), social rejection (i.e. high Reward Dependence) and perfectionism (i.e. high Persistence). Temperament is the emotional core of personality.
In addition, we are measuring character traits that describe a person’s goals, values and outlook on life. Hence, the TCI provides a way to distinguish whether an individual has an outlook of unity or separateness that guides their way of living. According to Cloninger’s psychobiological model of personality, individuals have an outlook of unity when they are highly developed in all three dimensions of character (i.e. self-directedness, cooperativeness and self-transcendence).
As a result, a person’s characteristic outlook can be measured with the TCI and the psychological climate of the workplace can be measured by the test of Koys and De Cottis. In this way, these two tests complement one another and may logically be combined in our assessment battery.
Cloninger’s test is based on his psychobiological theory of personality which proposes that there are four aspects of the temperament, based on four different brain systems. These are: (i) pursuit of novelty; (ii) avoidance of danger; (iii) dependence on social approval & (iv) persistence. Cloninger developed the TCI in order to study these four components. TCI actually represents a group of scales, which observe the differences among people in 7 basic dimensions that reflect the personal features of character and the temperament. Temperament is understood to be moderately stable throughout life, whereas character developed in response to individual and social influences on a person’s goals and values. The TCI has been widely translated and has been found to be useful in diverse cultures on all continents around the world [11
]. It is currently standardized for the Bulgarians, so it is particularly suitable for use in Bulgaria in combination with the Maslach’s scale. The full TCI has 240 items, but there is a short form with 140 items that is often adequate for research purposes related to health psychology [3
]. We have decided to employ the 5 point Likert scale 240 items TCI.
Previously, the TCI has been used mainly to perform psychological diagnostics of personality disorders and to study wellbeing in terms of health psychology. We will validate it for the first time (with the author’s cooperation) so that it can be properly used to understand the organizational psychology of the healthcare systems. We will use it for making a complex assessment of the psychological climate and wellbeing so that we will be able to recognize the symptoms of Burn-out syndrome at an early stage.
Significant levels of stress and professional burn-out have been well documented among healthcare specialists. One of the methods currently employed is Maslach’s Burnout Inventory (MBI), which consists of 22 questions and there is a 7-class scale for each one of them. Its proper application enables the analysis of the consequences of the professional burning process along with analysis of the psycho-emotional environmental effects. However, alone it may turn out to be insufficient in terms of the evaluation of numerous details and specific characteristics of every contingent studied. Therefore, we intend to combine the MBI with the test of Koys and De Cottis on psychological climate and the TCI. The TCI appears to be crucial in order to understand personal traits that explain individual differences in vulnerability to burn-out. The dimensions of the TCI have been described in detail elsewhere in relation to person-centered therapeutics [18
Self-directedness (i.e. purposeful and resourceful) has strong positive correlations with all health indexes, including those that are connected to the mental health (subjective satisfaction), social health and physical health (in terms of health perception). Cooperativeness (i.e. empathetic and helpful) is strongly associated with social wellbeing and subjective happiness. Self-transcendence (i.e. self-forgetful, transpersonal and spiritual) is strongly related to individual differences in positive emotions regardless of the development of the other two character traits [3
]. Our previous study has suggested that self-transcendence also has a strong role in reducing vulnerability to burn-out by facilitating the development of an outlook of unity and connectedness to what is beyond the individual self. Self-directedness and Cooperativeness are always crucial to a person’s capacity for working and loving, but unless self-transcendence is also developed, people often feel and act like they are separate individuals, which places a great burden on them psychologically and increases their vulnerability to burn out.
illustrates the outline of our study’s working hypothesis. It gives an account of the particular way the profile of personal vulnerability, the anomalies of the psychological climate and the Burn-out syndrome are interconnected [12
The relationship between personal vulnerability, anomalies of the psychological climate and burn-out.
We expect that the earliest and the strongest phenomenology of professional burn-out is observed as poor personal performance. However, as noted earlier, healthcare workers who are at risk for burn-out are likely to be perfectionists who are initially hard-working overachievers. In other words, burn-out may be a way for perfectionists to escape from trying to do the impossible. No one can be perfect, so what does a person do when they desire to be the best and perfect at everything they do? What happens when the demands of their work environment demand that they make no mistakes? The inevitable result is stress, guilt, shame, pain and other features of burn-out.
Such weak performance in terms of insufficient personal achievements and self-perfection is likely to be associated with a state of low self-directedness in TCI in people who were previously more self-directed. At the same time, decreased interest in work and loss of positive emotions are also part of the Burn-out Syndrome. The latter is expected to correlate with low self-transcendence as measured by the TCI. The Burn-out Syndrome is also connected to the feelings of social alienation and lack of support. These feelings are likely to be associated with low levels of Cooperativeness as measured by the TCI.