Burnout syndrome (BOS) can be interpreted as the extreme response of the chronic stress experienced in the workplace. The World Health Organization has recognised it as an occupational disease that has deleterious effects on physical and mental health and that can manifest with emotional, behavioural and psychosomatic symptoms.1

Historically, BOS has been associated with professions that involve close interaction with other people, especially those with a significant emotional burden. Therefore, health care professionals are a collective that is particularly vulnerable to this syndrome.2–4 Emergency care settings are stressful environments due to the heavy workloads, high patient expectations, long hours, lack of rest and significant responsibility for patients with severe disease.5 In addition, in the case of paediatrics, professionals do not only engage in the comprehensive care of the child, but also of the family, so the emotional burden may be even greater.6

There is no specific cause for the development of BOS, and it has been associated with psychological or psychiatric, sociodemographic, organizational and social factors.7,8

Characterising BOS in paediatric emergency care providers is of utmost importance, as its consequences can be devastating for them and their surroundings,8,9 and it has an impact on the quality of care, undermines the doctor-patient relationship and increases the risk of errors.9 Describing the problem and the associated factors makes it possible for individuals at risk to maintain a high level of awareness and to establish adequate prevention measures.

The primary objective of our study was to describe the prevalence of BOS in paediatricians involved in the delivery of paediatric emergency care (PEC).

The secondary objective was to analyse the association of BOS with different social, family-related, demographic and occupational factors and rewards.

We conducted a multicentre, cross-sectional survey of paediatricians working in paediatric emergency care settings in hospitals members of the Research Network of the Sociedad Española de Urgencias de Pediatría (Spanish Society of Paediatric Emergency Medicine) (RiSeuP-SPERG) between September 2019 and January 2020.

We recruited 32 hospitals in 12 autonomous communities (Appendix B4) and submitted links to the survey to 466 physicians. We received 392 completed responses (none of which were excluded), which corresponds to a response rate of 84.1%.

Prevalence of burnout syndrome

The scale identified BOS in 143 of the 392 participants, which corresponds to a prevalence of BOS of 36.5% (95% CI, 31.7 %–41.2%). The dimension that was in the pathological range most frequently was depersonalization (n = 281; 71.7%; 95% CI, 67.2 %–76.1%), followed by personal accomplishment (n = 259; 66.1%; 95% CI, 61.4 %–70.8%) and emotional exhaustion (n = 203; 51.8%; 95% CI, 46.8 %–56.7%) (Table 2 and Fig. 1). In 341 participants (87.0%), at least one dimension was in the pathological range.

Table 2.

Subscale levels in relation to burnout syndrome (392 submitted responses).

	Low n (%)	Moderate n (%)	High n (%)	Score mean ± SD
Emotional exhaustion	189 (48.2%)	97 (24.7%)	106 (27.0%)	21.1 ± 10.6
Depersonalization	111 (28.3%)	129 (32.9%)	152 (38.8%)	8.6 ± 5.0
Personal accomplishment	141 (36.0%)	118 (30.1%)	133 (33.9%)	35.5 ± 8.0

Values expressed as absolute frequencies and percentages. The levels of each subscale that define burnout syndrome are presented in boldface.

Figure 1.

Graphic representation of the number of participants at each level in each of the burnout syndrome subscales.

(0.12MB).

Ours is the first multicentre study on BOS of nearly nationwide scope conducted in Spain in physicians specialised in paediatrics and to explore factors associated with BOS with a multivariate, multilevel approach. We were able to obtain a large sample with a very high response rate and included the largest number of variables potentially associated with BOS ever analysed in a published study.

Although the MBI is the scale used most widely in the literature for the assessment of BOS, many different criteria have been proposed to define it. As a result, there is substantial variation in the reported prevalence of BOS, ranging from 7.1% to 76.1%.12,13 We found a higher prevalence in our sample compared to most other studies, in which it ranges between 20% and 25%,14–16 including one conducted in a similar population that applied the same diagnostic criteria, although in the United States.4 In any case, it is alarming that more than one third of clinicians exhibited moderate to high levels of burnout in the 3 dimensions used by Maslach and Jackson to define BOS and that nearly 90% had at least one dimension indicating moderate to high levels of burnout.

Individual traits such as anxiety or depression, which could have an impact on the emotional exhaustion dimension,17 and introversion were identified as risk factors for BOS.3 Similarly, a low emotional stability, psychological tension, neuroticism, among other personality traits, and mental health in general have been repeatedly described as factors associated with BOS.18–20 Our findings suggest that living in a conflictive environment with stressors in different spheres and underlying mental health problems (requiring treatment with antidepressant or anti-anxiety medication) can set the framework for the development of BOS.

On the other hand, coping mechanisms, such as socialising and having the support of family and friends to manage stressors,12,14,18–20 free time for personal leisure,21 hobbies and regular physical activity12 could have a protective effect. Our findings support this hypothesis, although the effect of families, significant others or children did not seem as important as proposed by other authors12,19,20 compared to having a circle of friends to spend time with regularly. This source of social support reduces or eliminates stressful stimuli, modifies how stressors are perceived, enhances coping mechanisms and improves mood, motivation and self-esteem.22

Some meta-analyses have identified age—in terms of youth and professional inexperience—as a predisposing factor for professional burnout.19,20 Although this association is gradual, in the sample under study we found the highest decrease in BOS after 9 years of work experience. It is hypothesised that individuals are more motivated and dedicated in the early years of their careers, which can turn against them due to a lack of professional recognition and the distancing from the social support network. As years go by, in addition to growing professional skills that increase their effectiveness, they go through experiences and develop adaptive strategies to cope with challenging situations, which increases resilience and the ability to tolerate difficulties in the workplace.23,24

When it came to occupational variables, we did not find evidence of the previously described association with the number of worked hours or on-call shifts a month,19,20 probably because these were quite homogeneous among the surveyed providers; however, the data did show that a high workload, in terms of the number of managed patients, has a negative impact on clinicians.

In addition to their amount, the nature of the tasks that professionals are responsible for plays a significant role in BOS.22 In Spanish hospitals, PEC is not organised as an independent department or unit or staffed with dedicated specialists in paediatric emergency medicine, and the providers that deliver care in these settings tend to be specialists in other fields. This is not the case in independent emergency departments, which tend to have better human and material resources and where care delivery is probably better organised, both factors which are also associated with BOS.20

In our sample, in spite of the dissemination of the survey through the RISeuP-SPERG, only 9 out of 32 participating hospitals (28%) had an on-call emergency care specialist in the premises at all times. This probably occurs in hospitals that manage more complex patients, and this very need of highly qualified personnel may be one of the contributing factors to higher prevalence of BOS observed under these conditions.

Working conditions also affect the dimensions of emotional exhaustion and depersonalization.11,20,25 Our study found that receiving recognition for one’s efforts and work from the closest professional circle (coworkers and immediate supervisor) plays a more important role than the atmosphere at work, institutional recognition and even employment stability. Similarly, in a recently published study that proposes a predictive model, not feeling appreciated by patients and not feeling appreciated by supervisors were two of the independent risk factors for BOS.26

An aspect worth considering is the extent to which these factors can predict the presence of BOS in different work settings. The multilevel analysis contributed some information on the subject, and allowed us to conclude that, in our sample, the variance in the presence of BOS, after controlling for those factors, could not be attributed to other differences between hospitals or autonomous communities, so that BOS would be chiefly determined by other factors at the level of the individual. This is particularly useful for the purpose of developing strategies to prevent and treat BOS, as it suggests that they will have the same impact independently of where they are implemented, and their results will only vary based on other individual-dependent factors.

In light of these findings, strategies for the early detection of BOS should be developed by screening for personality traits related with a propensity to anxiety or depression, programmes implemented to combat occupational stress by providing workers with coping skills27,28 and work-life balance promoted to ensure that clinicians have time for themselves and to strengthen their interpersonal relationships. Furthermore, from an organizational standpoint, the acquisition and improvement of knowledge and skills to tackle challenges in care delivery, the optimization of human and material resources to prevent excessive workloads and giving professionals meaningful recognition would improve wellbeing in the workplace and help fight burnout.1,11,29,30

There was no remuneration for this study. None of the main or collaborating researchers have received any payment for their participation in the development of the study and data collection and processing. The study did not receive any public or private funding.

The authors have no conflicts of interest to declare.

Ana Pérez Villena (Hospital Universitario Infanta Sofía); Yordana Acedo Alonso (Hospital Universitario Cruces); Elvira González Salas (Hospital Universitario de Salamanca); Estefanía Romero Castillo (Hospital Universitario Puerta del Mar); Anna Orejuela Ribera (Hospital Universitario Joan XXIII); Ramón Fernández Álvarez (Hospital Universitario de Cabueñes); Maria Ángeles García Herrero (Hospital Universitario Príncipe de Asturias); Ana Muñoz Lozón (Hospital Universitario Infanta Leonor); Daniel de la Rosa Sánchez (Hospital Universitario Insular de Canarias); Patricia del Río Martínez (Hospital de Mendaro); Mariano Plana Fernández (Hospital Universitario de Barbastro); Virginia Gómez Barrena (Hospital Universitario Miguel Servet); Ana Isabel Mohedas Tamayo (Hospital Universitario de Fuenlabrada); Carmen Hinojosa Mateo (Hospital Universitario del Tajo); Roberto Velasco Zúñiga (Hospital Universitario Río Hortega); Clàudia Coderch Ciurans (Consorci Sanitari de Terrassa); José Antonio Ruiz Domínguez (Hospital Universitario La Paz); Sebastià González Peris (Hospital Universitario Vall d’Hebron); Carlos Miguel Angelats Romero (Hospital Francesc de Borja); Neus Pociello Almiñana (Hospital Universitario Arnau de Vilanova); Ana Pizá Oliveras (Hospital Universitario Mútua de Terrassa); José Antonio Alonso Cadenas (Hospital Universitario Niño Jesús); Cristina Parra i Cotanda (Hospital Universitario Sant Joan de Déu); Izaskun Olaciregui Echenique (Hospital Universitario Donostia); Sara Pons Morales (Hospital Universitario Doctor Peset); Carmen Baltasar Navas (Hospital Universitario Virgen del Rocío); Sandra Yáñez Mesía (Hospital Universitario de A Coruña); María Reyes Balcells (Hospital Universitario Sant Pau); Nuria Gilabert Iriondo (Hospital Universitario Son Espases); Juan Luis Santos Pérez (Hospital Universitario Virgen de las Nieves); Sara Moralo García (Hospital Universitario Virgen de la Arrixaca); Garazi Plaza Fraga (Hospital Universitario de Basurto).