ARE WE GRADUATING PHYSIOTHERAPISTS WITH THE BURNOUT SYNDROME EVALUATING PHYSIOTHERAPY EDUCATION AT THE UNIVERSITY OF THE WESTERN CAPE ■ Seyi L A m o su n B S c Physiotherapy, P hD Physiology, Physiotherapy D epartm ent, U niversity o f the W estern Cape ■ Nokuzola D D antile B S c Physiotherapy, Physiotherapy D epartm ent, U niversity o f the W estern Cape INTRODUCTION The physiotherapy education program m e at the Univer­ sity of the W estern Cape, established in 1983, adm itted its first set of undergraduate students in 1984. From the onset, the training program m e w as accessible to students from historically disadvantaged com m unities in South Africa. The program m e has been com m itted to a student education which prom otes an interdisciplinary approach to health care, and the role o f physiotherapy at prim ary, secondary and tertiary levels of health care. The university also strives to be a leading academ ic institution in the provision of com petent and reflective practitioners of com prehensive health care. Burnout has been defined as a clinical syndrome of physical and em otional exhaustion involving the develop­ m ent of both a negative self-concept and a poor or negative 1 2attitude tow ards one's job . W olfe , through a study on physiotherap ists in acute care hosp ital settings in the United States of Am erica, developed a definition of burn­ out specific to physiotherapy. Burnout was defined as a feeling of em otional and physical exhaustion, coupled with a deep sense o f frustration and failure. The high incidence of burnout syndrom e in hum an service professions such as m edicine and nursing have been reported3. It is charac­ terised by three com ponents1'4 namely: 1. E m otion al exh austion : b ein g overextended and ex­ hausted by one's work. This is considered as the key aspect of burnout. 2. Depersonalisation: the developm ent of a negative and im personal response tow ards recipients of one's care or ^ABSTRACT ^ Burnout has been identified in physiotherapists. Based on the pos­ tulation that burnout actually begins during physiotherapy educa­ tional training, this study set out to determine if burnout exists among physiotherapy students in the University of the Western Cape. Using a modified version of the Maslach Burnout Inventory, 80.3% of the study sample (N=76) were found to have moderate to high levels of emotional exhaustion, while 14,5% indicated moderate to high levels of depersonalisation. However, 72.4% reported moderate to high levels of personal accomplishment. Some factors which contributed to burnout were also reported. It was concluded that burnout existed l^in the subjects involved in the study.________________________ J services. 3. Lack of personal accom plishm ent: the tendency to nega­ tivity w ith regard to one's achievem ents. The M aslach Burnout Inventory (MBI) is the com m only accepted tool for the m easurem ent of b u rn ou t1,4 6. It was originally designed for educators and health professionals. It has been shown to be a valid and reliable psychom etric instrument. The M BI consists of 22 item s and provides a m easure of degree of burnout in term s of three subclasses nam ely em otional exhaustion (EE), depersonalisation (DP), and personal accom plishm ent (PA). R espondents are re­ quested to rate the frequency w ith which they encounter each of the feelings expressed in the 22 item s on a 7-point scale in a Likert format, running from zero (never) to six (everyday). The scores for each subscale are classified as low, m od ­ erate or high according to ranges specified in the M BI m anual5, placing each individual on a scale of the degree of burnout. The scores in the EE, D P and PA subscales are categorised as shown in Table 1. The instrum ent is not a diagnostic tool since there is no score above or below which an individual is categorised as suffering from burnout or not. Respondents w ith high scores on the EE and DP subscales, and a low score on the PA subscale, are catego­ rised as being m ore burned out. Table 1: M aslach Burnout Inventory (MBI) scoring key 4 Subscale MBI score High M oderate Low Emotional Exhaustion 27 or over 1 7 - 2 6 0 - 1 6 Depersonalisatian 14 or over 9 - 1 3 0 - 8 Personal Accomplishment* 0 - 3 0 3 1 - 3 6 37 or over *Scored in opposite direction to em otional exhaustion and depersonalisation The prevalence of burnout am ong clinical physiothera- 1 2 7 8 4pists in the United States ' ' " , and A ustralia has been Q documented. Schuster et al surveyed 176 physiotherapists in the United States and found that about 53% believed they w ere experiencing burnout. In a sim ilar sam ple of A ustra­ lian physiotherapists w ith m ore than five years experience (reported by Scutter and G oold4), 35% of the subjects w ere found to have m oderate to high levels of em otional exhaus­ tion. In another sam ple of 129 physiotherapists w orking in rehabilitation hospitals in the United States, the m ajority of whom had three years or less experience, about 72% of the sample had m oderate to high scores on the em otional ex­ haustion subscale. Tw enty percent of the sam e sample scored high on the depersonalisation subscale, and 60% scored low on the personal accom plishm ent subscale1. Studies by Donohoe et a l1 and Scutter and G oold4 sug­ gested that burn ou t m ay be m ore prevalent in new ly Bladsy 69 Augustus 1996 SA Tydskrif Fisioterapie, Dee152 No 3 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) graduated physiotherapists. In a sample of 66 physiothera­ pists with five years or less experience and working in different clinical settings in A ustralia, 60% of the subjects recorded m oderate or high em otional exhaustion, 44% re­ ported m oderate or high depersonalisation, but only 6% had low scores in personal accom plishm ent. It was postu-Q lated by Kolb that the burnout syndrom e actually begins during the physiotherapy educational training. C om m ent­ ing on the study by Donohoe et al1, K olb9 reported that the factors contributing to burnout w ere also present am ong physiotherapy students, suggesting that there are num er­ ous physiotherapy graduates who are already burned out before they even start working. In order to test this postulation, Balogun et a lW first adapted the educators' version of the M BI and tested it w ith 21 physiotherapy students in the United States, on three different occasions in one academ ic year. The adapted in­ strum ent w as found to be reliable. A follow up study6 on 56 physiotherapy students from the sam e institution re­ vealed that overall, the students reported high em otional exhaustion and a m oderate level of depersonalisation, but high feelings of personal accom plishm ent, although senior students reported low er scores on personal accom plish­ ment. Sim ilar reports have been docum ented on m edical and dental students in the U nited K ingdom 11’14, and the United States15. Factors contributing to em otional exhaustion and drug addiction w ere identified am ong m edical students14. This led to reform s to im prove m edical education. The reform s included stress m anagem ent and self evaluation m anagem ent with a view to enhancing the health and w ell-being of m edical students. Further reform s in the cur­ riculum shifted em phasis from passive to active and self­ directed learning, and placed greater em phasis on health prom otion and prevention of disease. One of the m ission statem ents of the physiotherapy edu­ cation program m e at the University of the W estern Cape is the establishm ent of a program m e that is student-centred, in terd iscip lin ary , and b o th com m u nity- and hosp ital- based. The students are trained to play active roles, not only as providers of curative services, but also providers of rehabilitative and preventive services. Since burnout af­ fects the quality of care delivered, Kolb9 believes that unless the burnout rate am ong physiotherapy students is reduced, physiotherapy education program m es cannot turn out cli­ nicians who are confident, assertive, and realistic strate­ gists. The purpose of this cross-sectional study, therefore, was to- 1. Determine w hether burnout syndrom e exists among physiotherapy students in the U niversity of the W estern Cape; 2. Identify the factors associated w ith burnout in the stu­ dents. W e hypothesised that w ith the students' support sys­ tems available in the U niversity of the W estern Cape, and particularly in the D epartm ent of Physiotherapy, there is little or no cause for our students to exhibit the burnout syndrome. METHOD A ll the 126 physiotherapy students registered for the 1995 academ ic session w ere eligible to take part in the study. The survey instrum ent w as a questionnaire divided into three sections. The first section contained three ques­ tions about dem ographic characteristics nam ely age, gen­ der and year of study. The second section w as the m odified M aslach Burnout Inventory adapted by Balogun and his colleagues6, containing 22 statem ents about the potential im pact of the physiotherapy education program m e on the lives of the students. The third section included tw o open- ended questions. The first question requested students to indicate the factors in the training program m e w hich con­ tributed to burnout. The second question requested recom ­ m endations to reduce the burnout syndrome. The survey instrum ent w as first tested in a pilot study. Based on the feedback, some revisions w ere m ade concern­ ing the com plexity of the questions. Copies of the question­ naire w ere hand-delivered to the students, w ith a covering letter, at the beginning of the 4th term in 1995. Participation w as voluntary and anonym ity w as guaranteed. Scoring of the Maslach Burnout Inventory On the EE subscale, a subject w as considered to have a low score if the sum of the individual scores w as betw een 0-16 (Table 1). This suggested that the subject experienced a low level of em otional exhaustion. Sim ilarly on the DP subscale, a subject w as considered to have a low score if the sum of the individual score w as betw een 0-8. This w as also interpreted as a low level of depersonalisation. On the PA subscale, scoring is in opposite direction to EE and DP subscales. W hen the sum of the individual scores w as betw een 0-30, the subject w as considered to have a high score, and interpreted as having a high level of personal accomplishment. W hen the sum of the individual scores w as betw een 31-36, the subject w as considered to have a m oderate score, suggesting a m oderate level of personal accom plishm ent. A total score of 37 and above w as consid­ ered a low score, and interpreted as a low level of personal accomplishment. Data Analysis The M BI scores for each subject w ere calculated and categorised as high, m oderate or low on each of the three subscales5. The m ean score in each subscale w as calculated. The student t-test for independent sam ples, unequal sizes, w as used to determ ine if there w as a significant difference betw een the scores of m ale and fem ale students, and be­ tw een the scores for each of the four years of training16. The level o f significance was set at p<0.05 on the rationale that there is little or no chance of a disastrous outcom e if there is really no significant difference betw een the sexes, and 17betw een each year of training . RESULTS Seventy-six students (55 fem ales, 21 m ales) com pleted and returned the questionnaire. This gave a response rate of 60.3% from a total of 126 students. The average age was SA Journal Physiotherapy, Vol 52 No 3 August 1996 Page 70 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 20.9 years (17-37 years). The scores for the respondents are shown in Table II. Sixty-one students (80-3%) had moderate to high scores in em otional exhaustion, while 11 students (14.5%) had m oderate to high scores on the depersonalisa­ tion subscale. O nly 21 students (27.6%) scored low on the personal accom plishm ent subscale. An overall view of the respondents show s that m oderate scores w ere reported on the em otional exhaustion subscale and personal accom ­ plishm ent subscale, and a low score on the depersonalisa­ tion subscale. Table II: Sum mary o f M aslach Burnout Inventory (MBI) subscale scores ( N = 76) Subcales MBI score*1 High score Moderate score Low score Mean Medion SD° n (%) n(% ) n(% ) EE1 DP2 PA3 2 4 .0 0 3.9 9 3 1 .5 4 2 4 .0 0 3.5 0 3 1 .0 0 8 .5 6 3.5 8 7 . 6 / 2 6 (3 4 .2 ) 1 (1 .3 ) 3 7 ( 4 8 .7 ) 3 5 ( 4 6 .1 ) 1 0 ( 1 3 .2 ) 1 8 ( 2 3 .7 ) 1 5 ( 1 9 .7 ) 6 5 ( 8 5 .5 ) 2 1 ( 2 7 .6 ) 1 Emotional Exhaustionn Depersonolisation 3 Personal Accomplishment ” Standord Deviation Burnout is characterised by high scores on EE and DP, and lo w scores on PA scores Table III: MBI subscale scores for m ale and fem ale students Subscales Males (n = 2 1 ) Meon (SD) Females (n = 5 5 ) Meon (SD) EE* 2 6 .3 8 (9 .4 ) 2 3 .0 7 (8 .1 ) DP* 5 .2 4 (4 .5 ) 3.51 (3 .2 ) PA* 3 3 .8 6 (9 .0 ) 3 0 .6 5 (7 .0 ) * p < 0 .0 5 M ale students (n=21) had significantly higher scores (p<0.05) on the EE and DP subscales, and significantly lower scores (p<0.05) on the PA subscale, than the female students (n=55) (Table III). The m ean scores of the m ale students placed them in the high level of em otional exhaus­ tion, while the fem ale students were placed in the moderate level of em otional exhaustion. Both sexes fall into the low level of depersonalisation and m oderate level of personal accom plishm ent. Table IV: MBI subscale scores at different levels of training Year a f training EE” Mean (SD) DPb Mean (SD) PA' Mean (SD) lst-year (n = 2 7 ) 2nd-year (n = 18) 3rd-year (n = 9) 4th-year (n = 2 2 ) 2 3.81 (9 .4 ) 2 4 .8 9 (9 .2 ) 2 2 .8 9 (9 .9 ) 2 3.9 1 (6 .7 ) 4 .7 0 (4 .5 ) 3.11 (3 .1 ) 3 .4 4 (2 .4 ) 4 .0 5 (3 .1 ) 3 2 .3 7 (6 .9 ) 3 1 .5 6 (8 .1 ) 2 9 .8 9 (8 .6 ) 3 1 . 1 8 ( 8 . 2 ) 0 Na significant difference in emotional exhaustion (p > 0 .0 5 ) b No significant difference in deprsonalisation (p > 0 .0 5 ) c No significant difference in personal accomplishment (p > 0 .0 5 ) Com paring the m ean scores for students at different levels of training (Table IV), there were no significant dif­ ferences (p<0.05) betw een the scores on each subscale. H ow ever, on the EE subscale, 2nd-year students (n=18) had the highest m ean score while the 3rd-year students (n=9) had the lowest. On the DP subscale, the 1st- and the 2nd- year students had the highest and the low est m ean scores respectively. Sim ilarly, on the PA subscale, the 3rd- and the lst-y e a r students respectively had the highest and low est m ean scores. A perusal through the answ ers provided to the open- ended questions revealed that academ ic dem ands was the m ost problem atic factor contributing to em otional exhaus­ tion. Students w ere concerned about the m assive am ount of m aterial to be m astered in preparation for class tests or exam inations, but only two students recom m ended an in­ crease in the period of training from 4 years to 5 years. The m ajority of the students w ere also bored w ith didactic teaching and recom m ended that group work activities should take place m ore often. The students w ere also con­ cerned that there was very little social interaction am ong them selves, and betw een students and the academ ic staff. The 1st- and 2nd-year students desired a greater interaction with the senior students. The students in the 3rd and 4th years found the assessm ents at the end of each clinical block very stressful. At the m om ent, academ ic staff are prim arily responsible for assessing the clinical ability of the students at the end of each clinical block. The students recom ­ mended that clinical supervisors should have a greater responsibility in the end-of-block assessm ent. They also requested that m ore tim e to be spent in the clinics than in the classroom. Furtherm ore, they requested periodic posi­ tive feedback from their clinical supervisors and lecturers. DISCUSSION The study set out to determ ine w hether burn ou t syn­ drom e exists am ong physiotherapy students at U niversity of the W estern Cape. U sing the adapted version of the M aslach Burnout Inventory6, the data we collected from 76 students (60.3% of the student population) revealed that em otional exhaustion was the m ost prom inent burnout characteristic dem onstrated. A pproxim ately 80% of the subjects reported m oderate to high scores on the em otional exhaustion subscale; few er students (14.5%) dem onstrated m oderate to high depersonalisation. O n the positive side, 72,4% of the subjects reported m oderate to high scores on personal accom plishm ent subscale. Since em otional ex­ haustion has been identified as the key aspect of burnout4, our findings suggest that the burnout syndrom e exists am ong the students involved in this study. In addition, our graduating students (4th year) reported higher levels of em otional exhaustion than the 1st and 3rd year students. Q This confirm s the suspicion of Kolb that there are num er­ ous physiotherapy graduates who are already burned out before they even start working. The overall outcom e of this study was com pared with that of Balogun and others6, which was carried out in an institution which also caters prim arily for students from disadvantaged com m unities in the U nited States. In our study, though the students experienced a m oderate level of em otional exhaustion, they expressed a m oderate feeling of personal accom plishm ent. Balogun et a f reported a high feeling of personal accom plishm ent am ong their students in spite of the high level of em otional exhaustion. On the Bladsy 71 Augustus 1996 SA Tydskrif Fisioterapie, Dee152 No 3 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) depersonalisation subscale, the students in this study had a m ore positive opinion of them selves and the people they interacted with, than the students in the study by Balogun et a t . A better understanding of the com m unities w hich the two institutions serve m ay reveal the reasons for the differ­ ences reported. Studies carried out on m edical students identified sex differences in the way students responded to the stress of m edical education14. Fem ale students reported m ore nega­ tive affect and physical sym ptom s, and a greater decrease in positive em otion and perceived peer friendliness than the m ale students. In our study, m ale students reported higher levels of em otional exhaustion and depersonalisa­ tion, and lower levels of personal accom plishm ent than the fem ale students. W e recom m end that further studies be carried out to identify the reasons for the gender difference. The subjects in this study reported a num ber of factors contributing to em otional exhaustion in the physiotherapy education program m e at the University of the W estern Cape. A com m on struggle faced by students is how to strike a healthy balance betw een their personal and academic lives. Students often place greater priority on one to the detrim ent of the other. This leads to im balanced lifestyles, w hich have been identified as factors contributing to physi­ cal and em otional exhaustion, depression and drug addic­ tion14. A com petitive educational environm ent also tends to prom ote conflicts betw een student and student, and betw een student and the lecturer. These conflicts are poten­ tially stressful and m ay lead to em otional exhaustion6. It has also been observed that periodic review of the physio­ therapy education curriculum often resulted in increased academ ic dem and on students and lecturers, leading to further em otional exhaustion. A n appreciable num ber of our subjects expressed negative and im personal responses tow ards their school w ork, classm ates, lecturers and clini­ cal supervisors. Based on the responses of the students in this study, we recom m end that a m odification of the educational environ­ m ent should be considered in order to address the stressors responsible for em otional exhaustion. A reduction in the stressors may assist in our m ission to train com petent, reflective practitioners. It may also be beneficial for stu­ dents, lecturers, clients and prospective em ployers. CONCLUSION The burnout syndrom e exists am ong physiotherapy stu­ dents in the U niversity of the W estern Cape. There is a need to identify the causative factors and m ake necessary adjust­ ments. REFERENCES 1. D onohoe E, N aw aw i A, W ilk er L et al. F actors associated w ith bu rn ou t o f physical therapists in M assach usetts R ehab ilitatio n H ospitals. Physi­ cal Therapy 1993;73:750-761. 2. W olfe G A. Burnou t o f therapists: inevitable or preventable? Physical Therapy 1981;61:1046-1050. 3. Schw eitzer B. Stress and bu rn o u t in ju n io r d octors. S ou th African M edical Jou rn al 1994;84:352-354. 4. Scu tter S, Goold M . Burnout in recently qualified p h ysioth erap ists in South A ustralia. A u stralian Jou rn al o f Physiotherapy 1995;41:115-118. 5. M aslach C, Jack son S E. M aslach B urn ou t Inventory M an u al. (2nd edition) Palo A lto, CA: C onsu ltin g Psychologists Press, 1993. 6. Balogun J A , H elgeino e S, Pellegrini E. T est-retest reliability o f a p sy ­ chom etric instrum ent designed to m easure physical therapy stud ents' burnout. P erceptual an d M otor Skills 1995;81:667-672. 7. D echard G J, Present R. Im p act o f R ole Stress on Physical T herap ists' Em otional and P h ysical W ell-being. Physical T herapy 1989;69:713-718. 8. Schu ster N D , N elson D L, Q uislin g C. Burnout A m o ng Physical Therapists. Physical Therapy 1984;64:299-303. 9. K olb K. G rad u atin g Burnout C andidates. P hysical T herapy 1994;74:264- 265. 10. Balogun J A, P ellegrin i E, H elgem oe S et al. Burnou t Syn drom e in Physical Therapy Stu dents: Facts or Fiction? A bstract. P roceedings of the 12th International C ongress o f the W orld C on federation for P h y si­ cal Therapy 1995;530. 11. C o le s C . In tr o d u c tio n : M e d ic in e and S tre s s . M e d ica l E ducation 1994;28:3-4. 12. C oles C. L earnin g to C ope: Stress and M ed ical C areer D ev elo p m ent in the United K in gdom . M edical Education 1994;28:18-25. 13. Benbow E W. Som e Effects o f U rban V iolen ce on the Lives of D ental Students. Jou rn al o f D ental Education 1994;58:221-224. 14. W olf T M. Stress, C o p ing and H ealth: E nhan cing W ell-bein g d u ring M ed ical School. M edical Education 1994;28:8-17. 15. Toew s J A , L ock y er J M , D obson D J G et al. Stress and H arassm ent: Perception of Stu den ts and R esidents. A cadem ic M ed icin e 1993;68:S46- S48. 16. C u rrier D P. Elements o f Research in Physical Therapy. (2nd edition) Baltim ore: W illiam s and W ilkins 1984. 17. H icks C M. R esearch o f Physiotherapists: P roject D esign an d A nalysis. (2nd edition) C hurchill Livingstone 1995. NATIONAL PHYSIOTHERAPY BACK WEEK 1 6 -2 1 SEPTEMBER 1996 Dear Member, Enclosed with this issue of The SA Journal Physiotherapy you will find a poster and an information brochure con­ cerning Back Week: 16-21 September 1996. You are kindly requested to familiarise yourself with the strategy, adapt it to your particular circumstances and be pro-active in your community in order to ensure that Back Week will be a resounding success! We will endeavour to do whatever we can to support your efforts on a national level. ^ S / O T E R A P ^ All suggestions and q ue ries a re m ost welcome and can be directed to the Public Relations Organiser of your province, or to Fiona Pringle, National Back Week Organiser (031) 266-9279. Thank you for your co-operation, and wishing you a successful Back Week. ■ Dr Lisa de Blois Executive Director SA Journal Physiotherapy, Vol 52 No 3 August 1996 Page 72 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )