INT'L. J. O F PUB. ADMIN.

, 1 4 ( 1 ) , 4 3 - 5 7 ( 1 9 9 1 )

HEALTBCARE PROFESSIONAL A!lTEND THYSELF:

TBE EPIDEMIOLOGY OF BURNOUT IN SEVERAL SETTINGS

Robert T. Golembiewski
Department of Political Science
University of Georgia
Athens, GA 30602
and
Robert Boudreau
Faculty of Management
University of Lethbridge
Lethbridge, Alberta, CANADA

This paper estimates the incidence and severity

of experienced stress among several convenience
populations in healthcare settings, with total N
surpassing 7,500. An 8-phase model of burnout places
many healthcare providers in the most-advanced phases
--approximately 47 percent. This is substantially
higher than the record in 25 organizational
populations, N = 5,310, which are largely managerial
and white-collar in composition. Selected missing
populations approximate the distribution in these 25
populations.
This paper suggests the special urgency of
remedial attention to experienced stress in
healthcare settings, building on successful
interventions in several settings. Assignments to
the highest phases of burnout imply a large battery
of deficits and deficiencies--low satisfaction, high
turnover, poor performance appraisals, greater
physical symptoms, and so on, based on research with
some 300 covariants of the phase model of burnout.

Copynght O 1990 by Marcel Dekker, Inc.

 GOLEMBIEWSKI AND BOUDREAU

In both ideal and practice, the healthcare

worker attends to others in need, and that is as it
should be, of course. Technology plus caring praxis
can do wonders, and more and more people not only
expect medical wonders to occur but are increasingly
insistent that they get their full share.
Growing evidence suggests that this attention
cannot remain a one-way street, however. Data
presented here imply that the healthcare professions
need to direct as telling attention to themselves as
they do to their clients and patients. Indeed, it
requires no great stretch to envision the conditions
under which the failure to attend to self may
eventuate in decreased service to others.
This article takes a limited approach to this
general point by looking at the incidence and
severity of stress or burnout in several healthcare
settings. This approach requires three emphases.
Thus an initial section introduces the phase model of
burnout. Then the covariants of the phases are
illustrated, with respect to both virulence and
persistence. Subsequently, the incidence of the
phases in several healthcare settings will be
estimated, as one indicator of the magnitude of the
burnout problem facing those professionals.

PHASES OF BURNOUT

Much anecdotal and clinical observation has for

a decade or more pointed up the relevance of burnout
to a person's well-being (I), (2). The dis-ease is
viewed conceptually as the degree to which
experienced stressors compare to a person's normal
EPIDEMIOLOGY OF BURNOUT 45

coping skills and attitudes. As those stressors at

first challenge a person's comfortable coping limits,
and then exceed them, so also is the individual
likely to experience various deficits or
deficiencies. Physical complaints increase;
relationships tend to suffer; and various kinds of
abuse increase--of substance, of self, and of others
(3).
Only recently has it become possible to assess
how many people have which degrees of burnout,
however, with the phase model of burnout providing a
particularly attractive and convenient approach to
diagnosis (4), (5). What we have learned is
troubling, as the summary details to follow will
establish.
Two sets of details support this dour
assessment. The first deals with the phase model,
and the second reviews its covariants.
1. Phase Model of Burnout. The present
approach rests on the items of the Maslach Burnout
Inventory, or MBI (6). The MBI is a convenient
paper-and-pencil instrument, and its items tap three
sub-domains of burnout or experienced stress:
o Depersonalization, on which higher
scores isolate individuals who tend
to reify their personal relation-
ships, who think of others as things
or objects;
o Personal Accomplishment (Reversed),
on which lower scores identify in-
dividuals who believe they are doing
well on a task that is worthwhile;
 GOLEMBIEWSKI AND BOUDREAU

o Emotional Exhaustion, on which

higher scores indicate individuals
who are at or beyond their
cornforcable coping skills/attitudes--
they are at "the end of the rope" in
emotional terms

Personal Accomplishment is reversed to inhibit

response-set.
The phase model makes a use of the three
sub-domain scores beyond that intended by Maslach.
Using norms from a large population, (7) each
individual is assigned High or Low status on each of
the three sub-domains. Assuming only that those
sub-domains are increasingly virulent in the order of
their introduction, these eight combinations--or
z3--of progressive virulence can be identified:
Phases of Burnout
I I1 I11 N V VI V I I VIII

Depersonali- Lo Hi Lo Hi Lo Hi Lo Hi
zatioil
Personal
Accomplish- Lo Lo Hi Hi Lo Lo Hi Bi
ment (REV)
Emotional Lo Lo Lo Lo Hi Hi Hi Bi
Exaustion
Conceptually, the phase model does no=require
that an individual go through each phase
sequentially. The model proposes only that the
several phases are progressively virulent, however
one gets into one phase or another. Two modes of
onset are accommodated by the model, moreover.
EPIDEMIOLOGY OF BURNOUT

Chronic onset is due to persisting, unattractive

features of work and the worksite, and its single
flight-path is I ---> I1 ---> IV ---> VIII. Acute
onset is precipitated by some traumatic stimulus, in
contrast, and multiple flight-paths are possible.
Thus the sudden death of a loved one might precipi-
tate a I into V and later, given a difficult grieving
process, into VII or VIII.

Regularly and robustly, almost ail 02 300

variables thus far investigated by several teams of
investigators show growing deficits or deficiencies
as the phases are compared I ---> VIII ( 8 1 , ( 9 1 ,
1 0 1 . To illustrate, phase by phase, among
numerous other features:
broad ranges of perceptions or attitudes
about the worksite deteriorate -- e.g.,
satisfaction and job involvement fall,
tension at work increases, and so on
performance appraisals tend to decrease
physical symptoms increase
turnovez grows
self-esteem falls
various clinical indicators of mentai
health deteriorate
interpersonal and group properries
suggest a declining quality of social
and emotional life at work -- e.g.,
group cohesiveness is down, social
support falls, and so on.
 GOLEMBIEWSKI AND BOUDREAU

Along with these all-but-unanimous indicators of

virulence, phase by phase, burnout levels seem to be
substantially stable. Over extended periods of
observation up to a year, a person's phase assignment
tends to remain stable or to return to a narrow range
of phases if movement does occur (12). Of course,
this suggests the basically-chronic nature of
burnout.
In a few words, although details are beyond the
scope of this paper, the phases of burnout seem both
virulent and persistent.

PHASES IN HEALTHCARE SETTINGS

Such considerations suggest the relevance of

burnout in healthcare settings, but what is the
approximate magnitude of the challenge? No random
sample of professionals is available to provide a
firm estimate, but a number of convenience samples
encourage close attention to burnout in healthcare
settings. Tables 1 and 2 provide a summary of the
distributions of phases observed in a number of
healthcare settings, with the total panel including
over 8,500 persons. Some nurses are included in
Table 1.
No doubt, many people will have different
standards in this matter, but the total picture
suggests a mammoth problem. Thus, in Table 1, nearly
1 in every 2 employees in the healthcare settings
surveyed (47.0 percent) is classified in Phases VI-
VIII. For the nurses, the distribution approximates
1 in 3 (36.4 percent). See Table 2.
EPIDEMIOLOGY OF BURNOUT 49

Looked at positively, overall, a substantial

proportion of those surveyed fall in Phases 1-111.
That approximates 53 percent in the case of nursing
populations (see Table 2); and it surpasses 38
percent for total employment in eight healthcare
settings with over 6,700 respondents (see Table 1).
The overall picture is daunting. Nurses are
relatively better-off than total healthcare
employees, but even the nurses have alarming
incidences of Phases VI-VIII. The overall results
are influenced substantially for total employees by
cases #1 and 8, which represent a healthcare segment
with low wages and difficult working conditions for
many employees.

FINER-TUNING OF TEE PBASE DISTRIBUTIONS

These gross distributions of phases may be put

in sharper perspective, perhaps, by a brief
discussion of eight points. First, although it may
come as little consolation, the "burnout problem" as
reflected in the distribution of phases is apparently
not unique to healthcare settings. Data are adequate
only for ballpark comparisons, coming as they do from
convenience populations. Nonetheless, Table 3
summarizes phase distributions from two contexts: 25
white-collar and managerial settings; and 2 heavy-
industry settings, where the work is difficult and
the worksite hot as well as dirty (13). Data from
healthcare populations in Tables 1 and 2 fall in the
mid-ranges of Table 3.
Second, Table 3 does not imply similar numbers
or degrees of stressors in all three of the contexts
 TABLE 1

Summary, P h a s e s o f B u r n o u t , i n V a r i o u s H e a l t h c a r e Settings
Phases of Fkrnout, in percent
I I1 111 IV v VI VII VIII

1. A l l operating and supervisory 29.1 0.0 0.0 14.1 0.0 18.5 9.5 28.9
employees of a chain of nursing
hams, generally considered the
"Cadillac" of their type, S i t e
A, N = 2389

2. A l l arployees of a mn-profit,
~ t i o n a, lf dl-service
hospital, excluding doctors,
N = 772

3. A l l errplayees of a ran-profit,
denrninational, full-service
hospital, excluding doctors,
N = 637

4. A l l employees of a full-care
cxmnunity hospital i n Can-
adian regional c e n t e r i n
r u r a l area, excluding drxtors,
S i t e B, N = 404
EPIDEMIOLOGY OF BURNOUT

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GOLEMBIEWSKI AND BOUDREAU
EPIDEMIOLOGY OF BURNOUT
54 GOLEMBIEWSRI AND BOUDREAU

--healthcare, white-collar, and industrial. Rather,

the focus is on the resultant of whatever stressors
are experienced, by each individual, as discounted by
each person's coping attitudes or skills. Selection,
education, and training processes may well permit
healthcare workers to experience more frequent and
more intense stressors than industrial workers. The
ethos and ideology of people-helping professions no
doubt operate in a similar direction. But the phase
model focuses not on how much stress; rather advanced
phases of burnout seek to isolate those individuals
who are experiencing too much strain, given their
individual standards applied to whatever stressors
they experience.
We lack demographic data on many of the health-
care settings. Elsewhere, however, most demographic
variables account for small percentages of the
variance in burnout even where "statistical
significance" is observed (14). Thus women tend a
bit toward more advanced phases than men, but not
much. And younger employees and the older ones have
better profiles on the phases than those in the mid-
years, but this tendency is modest.
Third, the healthcare distributions in Tables 1
and 2 understate the percentage of advanced phases,
if anything. Specifically, our convenience
populations do not include large hospitals in
metropolitan settings, and especially those in
impoverished areas where phase distributions may well
be more extreme than in Tables 1 and 2.
Fourth, generally, the summary distributions in
Table 1 do not include medical doctors. Especially
where large numbers of residents or interns are
EPIDEMIOLOGY OF BURNOUT 55

involved, this may generate a conservative bias in

the phase distributions in Table 1.
Fifth, the distributions of phases vary some,
context by context. But even the "best1'distribu-
tions imply no substantial peace-of-mind concerning
burnout in healthcare settings--the 20 percent seems
to provide the estimate of the most-favorable
distribution of persons in Phases VI, as an estimate
of the proportion of persons in Phases VI, VII, and
VIII. The "worst" distributions place 50 percent or
more of the respondents in the three most-advanced
phases of burnout.
Sixth, looked at in another way, local
environments seem to differ substantially in their
tendency to induce advanced phases in members. Even
though the "best" environments imply major
difficulties, that is, local properties can reduce
the incidence of advanced phases (15). Of course,
local features also might exacerbate burnout
problems. For example, Hokkaido, Japan, pays a
premium for healthcare workers because of its
isolation and climate. Perhaps not coincidentally, 7
healthcare settings there approximate 70 percent of
all employees in Phases VI-VIII.
Seventh, only a survey of a randomly-selected
population of healthcare professionals will permit an
unqualified estimate of the distributions of phases
among different kinds of healthcare workers. Despite
the substantial number of persons who have been
assigned to phases in Table 1 and elsewhere, all come
from convenience populations and purists thus can
complain that the phase results are not representa-
tive. The growing evidence urges attention to this
crucial matter.
 GOLEMBIEWSKI AND BOUDREAU

Eighth, early evidence suggests an ability to

consciously induce work environments that ameliorate
advanced burnout (16). Details are beyond the scope
of this analysis, but the phase model holds promise
not only for describing existing conditions but also
for prescribing ways to reduce burnout by inducing
appropriate worksite conditions.

CONCLUSIONS

In short, burnout seems a significant problem in

even the best of the healthcare settings so far
studied. In general, the distributions of advanced
phases do vary from case to case, but only in this
narrow range: from bad to worse.
So, we conclude as we began. Healthcare
professional attend thyself.

1. Freudenberger, Herbert J. Burnout: The High

Cost of Hiqh Achievement. Garden City, N.Y.:
Anchor Press, 1980.
2. Maslach, Christina. Burnout: The Cost of
Caring. Englewood Cliffs, N.J.: Prentice-Hall,
1982.
3. Maslach, ibid., esp. chaps. 1 and 2.
4. Golernbiewski, Robert T., Munzenrider, Robert F.,
and Stevenson, Jerry G. Stress in Orqanizations.
Praeger, 1986.
5. Golembiewski, Robert T., and Munzenrider, Robert
F. Phases of Burnout. New York: Praeger, 1988.
6. Maslach, Christina, and Jackson, Susan E.
Maslach Burnout Inventory. LaJolla, CA.
Consulting Psychologists Press, 1982, 1986.
EPIDEMIOLOGY OF BURNOUT 57

Golembiewski, Robert T., and Munzenrider, Robert

F. ffPhases of Psychological Burnout and

Burke, Ronald J., Shearer, Jan, and Deszca, Gene.

"Burnout
- -- .- Amona Men and Women in Police Work."
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Deckard, Gloria. Work, Stress, Mood and

Ecological Dysfunction in Health and Social
Service Settings. Unpublished doctoral
dissertation, University of Missouri, Columbia,
MO., 1985.
Golembiewski, Munzenrider, and Stevenson, 9 .
&. , 1986.
Golembiewski and Munzenrider, OJ. u.,1988.
Golembiewski, Robert T., Deckard, Gloria, and
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Assignments," Journal of Health and Human
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Novelli, Luke, Elloy, D., and Flynn, F. R.
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in press.
Golembiewski and Munzenrider, o ~ .G.,
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Golembiewski and Munzenrider, ibid., 1988.
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