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364-72.

Longitudinal predictors of burnout in HIV/AIDS health professionals Lydia Bennett Deparbwnt of Behavioural and Social Sciences an Nursing and Department of Public Health, University of

Margaret Kelaher Department of Public Health, University of Sydney

S Y d V

Abstract This study examined causes of burnout in &tors, nurses and social w h caring for patients in HIV/AIDS units. There w e 84 participants at Time I (1990) and 134 at Time 2 (1991). Thc results f k u s on the longiiudinul subsample of 32 who participnted in the study at both times. Path analysis was wed to explore relationships between burnout at Tame 2 and age, hours pc’ week in HIV/AIDS work, and external coping style at Time 1. Oldcr age was related to lower levels of burnout at Time 2. Hours pc’ week in HIV/AIDS work was related to levels of bumout. Participants using an extemal coping styk were more likely to score highly on burnout at Time 2. Where parsibk, man- agement should avoid remiting young, incxpcnkued stuff without addressing burnout issues. Workshop to teach staff internal coping shills are recommended. Units might promote the fqchrocial achimments of stafl, shijing away prom the tra- ditional cun-barcd achievement measures. (Aust J Public Health 1994; 18: 334-6)

urnout in health care professionals working with B HIV (human immunodeficiency virus) and AIDS (acquired immune deficiency syndrome), or indeed any chronic fatal disease, is becoming a disturbingly common problem. Burnout is usually defined as a combination of emotional exhaustion, depersonalis- ation and lack of personal accomplishment. Burnout contributes to high turnover rates which in turn result in expertise being drained from areas like HIV/AIDS. Reducing burnout is crucial to reducing

Correspondence to Dr Lydia Bennett. Senior Lecturer, Depart- ment of Behavioural and Social Sciences in Nursing, M 0 2 . Univer- sity of Sydney, NSW 2006. Fax (02) 517 0315.

training costs and maintaining levels of patient care. Reduction requires identifying personal and environmental determinants of burnout and methods for reducing psychological harm associated with this work environment.

Several studies have explored the relationships between age, the amount of time spent in HIV/AIDS work, and stress or burnout. Older subjects are less likely to experience b~rnou t . ’ .~ ,~ Burnout has been associated with tenure in a particular job.5 This may interact with individual differences and be a function of the type ~fwork.~.’ Horstman and McKusick found that the more time physicians spent in contact with AIDS patients, the more likely they were to experi- ence psychological distress.!j Practitioner burnout may be more a function of concentrated exposure to, rather than longitudinal contact with, the disease.

Burnout may also depend on the availability of dif- ferent coping strategies. Rotter’s distinction between i n t m l s , who credit themselves for the ability to influence the environment and extenals, who per- ceive events as being under the control of factors external to themselves,9 has been applied to the study of burnout among health care workers. Higher levels of burnout have been associated with reliance on external strategies while lower levels are associated with internal strategie~.~.’~ Martin reported that coping styles involving mental and behavioural disen- gagement were related to higher burnout scores and more frequent and more common intentions to leave the AIDS unit.” Accordingly, education about

334 AUSTRALIAN JOURNAL OF PUBLIC HEALTH 1994 VOL. 18 NO. 3

coping may assist staff in dealing with the difficulties of providing HIV/AIDS-related care.

This study explored the precipitating and preven- tive factors for burnout in HIV/AIDS health care professionals. Demographic variables such as age, months in a unit and hours per week working in HIV/ AIDS-related activities were examined. It was pre- dicted that higher age would be associated with lower levels of burnout.J If the chronicity of work contrib- utes to b ~ r n o u t , ~ then months in the unit would pre- dict levels of burnout. If intensity is the important determinant,H then hours per week would be expected to predict levels of burnout. Alternatively, both chronicity and intensity might contribute to burnout. Burnout would be expected to affect indi- viduals who use coping strategies assuming an exter- nal locus of control than those who emphasise personal agency in their coping strategies.

Method Participants Respondents were health professionals from hospital units in which a substantial proportion of patients were being treated for HIV/AIDS. Units having only a small number of such patients were not included to avoid dilution of the sample. Six units took part, three from New South Wales, two from Victoria and one from Queensland. The response rate was 74 per cent, with 84 respondents at Time 1 (1990). At Time 2 (1 991), 134 respondents volunteered their partici- pation, 62 per cent of those asked. A longitudinal subsample consisted of 32 respondents who partici- pated in the study at both times. Of these, 19 were nurses, 7 were doctors and 6 were allied health workers, a representative spread of occupational groups according to total sample proportions. The mean age of the 32 respondents at Time 2 was 34.50 (standard deviation f8.84) years. They spent an aver- age of 36.28 (k9.42) hours a week working with AIDS patients and had been employed in the field for an average of 33.37 (f18.02) weeks.

Questionnaire The questionnaire measured variables including age, months in the unit and hours per in week HIV/AIDS- related work. Staff listed how much of their time was spent in HIV/AIDS-related work (as opposed to other activities in the working week).

The Maslach Burnout Znventoty (MBI) was used to measure burnout.! It consists of three scales: emo- tional exhaustion, lack of personal accomplishment and depersonalisation, which each correspond to a component of burnout. Previous research studies indicate the high reliability and validity of the inventory.

Ways of Coping Scale (revised WOC) measured how many different coping strategies were used and how often they were used by respondents.'' A factor analysis of scores from this sample suggested that there were two main types of strategy: external (a-coefficient reliability = 0.58) and internal (a- coefficient reliability = 0.8 1). Internal strategies were those involving personal agency, including posi- tive, self-expressive, active, vigilant and time-out coping strategies. External coping strategies were those derived from a position of powerlessness where

Time 1

BURNOUT I N HlV/AlDS PROFESSIONALS

Time 2

I3 = -0.62'

0=0.72'

0=0.39*

I 0 = 0.73'

Burnout

AUSTRALIAN JOURNAL OF PUBLIC HEALTH 1994 VOL. 18 NO. 3 335

BENNETT AND KELAHER

Time in the area, as measured by months in a unit (p = 0.24, P > 0.01), and internal coping (p = -0.20, P > 0.01) were not significantly related to burnout in this sample.

Discussion The data must be interpreted with caution since the sample size is small and power is likely to be low. However, analysis did indicate that there were no sig- nificant differences between people who continued in the study and people who did not. The results appeared to be consistent with the existing body of research on burnout.

The results indicated that burnout was inversely associated with age, a finding which is consistent with a number of other These results suggest that when recruiting staff for the area of HIV/AIDS, management should, if possible, avoid hiring younger staff members without attention to burnout issues. Staff who are older may be better able to avoid burnout. An alternative strategy to selective hiring may be to determine which aspects of coping are age- related and provide facilities for older staff to share their expertise with younger members of staff. This policy would be consistent with Coyle and Soodin's contention that access to a supervisory relationship may reduce stress in the HIV/AIDS area, particularly for inexperienced staff.IJ

Hours per week in HIV/AIDS caregiving was related to burnout. This supports the earlier findings that concentrated exposure to AIDS was linked to higher Unlike the findings of Berkeley Planning associate^,^ length of time in the area was not related to burnout in this sample. This supports the suggestion that concentrated exposure rather than time is responsible for burnout in this area.s Conse- quently, it may be beneficial to encourage staff to rotate through areas of work.

Respondents who use primarily an external coping style are more likely to report high levels of burnout. This supports studies which link external coping styles to increases in stress and b u r n o ~ t . ~ . ~ ~ . ~ ~ Staff should be taught to use fewer external coping

strategies. This may be encouraged by team meetings that involve all staff in problem solving and active involvement in unit activities.

Workshops to teach staff internal coping skills are also recommended. Team work needs to foster a per- ception in staff that they cun make a difference to the patient's condition. Focusing on the psychosocial achievements of staff assists them to internalise their ability to influence outcomes and to recognise factors other than cure as measures of success. This may subsequently reduce the burnout associated with external coping styles for staff working in HIV/AIDS. References

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Lazarus RS, Folkman S. Stress appraisal and coping. New York Springer. 1984: 328-33. Coyle A. Soodin M. Training, workload and stress among HIV counsellors. AIDS Care 1992; 4: 217-21. Bell AP, Weinberg MS, Hammersmith SK. Sexual peJzrmce: its d c u e w in men and womm. Bloomington: Indiana Uni- versity Press, 1981.

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